A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis

Although several cases of severe hypoalbuminemia resulting from rice milk have been described in the past, today the use of rice milk without nutritional counseling to treat eczema is still a continuing, poor practice. We describe a kwashiorkor case in an infant with severe eczema exclusively fed with rice milk. It is well documented that rice milk is not a sufficient protein source. Moreover, only a small portion of eczema is triggered by food allergy. In conclusion this case raises the importance of managing dietary changes facing food allergies with responsibility for specialized consensus among pediatricians, nutritionists, endocrinologists and allergists all of them specialist professionals.

Skin prick test results to artesunate in children sensitized to Artemisia vulgaris L

Artemisia vulgaris L and Artemisia annua L (Chinese: qinghao) are similar plants of the Asterbaceae family. Artesunate, a semi-synthetic derivate of artemisin which is the active principle extract of the plant qinghao, has antimalarial properties. Some cases of severe allergic reactions to artesunate have been described. The purpose of this study was to evaluate the association between positive skin tests to Artemisia vulgaris L allergen and a preparation of injectable artesunate. A total of 531 children were skin prick tested with inhalants (including Artemisia vulgaris L), foods, and artesunate. Among the 59 patients positive to Artemisia vulgaris L only one child was also positive to artesunate. No child was positive to artesunate in those negative to Artemisia vulgaris L. We conclude that Artemisia vulgaris L sensitization is not associated with sensitization to artesunate; consequently, skin test to artesunate should not be carried out before using the drug considering the rare allergic reactions.

Amoxicillin allergy in children: five-day drug provocation test in the diagnosis of nonimmediate reactions

BACKGROUND

The drug provocation test (DPT) is the gold standard to rule out drug hypersensitivity. There are standardized DPT protocols to diagnose immediate reactions to drugs, but not for nonimmediate reactions.

OBJECTIVE

The aim of this study was to show the sensitivity and specificity of an allergy work-up that included a 5-day DPT in children with histories of nonimmediate reactions to amoxicillin through focusing on a pediatric population with histories of immediate and nonimmediate reactions to amoxicillin.

METHODS

Two hundred consecutive patients with histories of amoxicillin reactions referred to the Allergy Unit of Anna Meyer Children's Hospital for suspected drug allergy from 2008 to 2011 underwent in vivo tests with the culprit drug according to European Academy of Allergy and Clinical Immunology guidelines. Moreover, most of those children, regardless of the skin tests results, were challenged with amoxicillin for a total of 5 days.

RESULTS

In 4 years, 200 patients were evaluated for a history of drug hypersensitivity to amoxicillin. The majority of patients (76%) had a history of mild nonimmediate reactions. All 200 patients underwent skin tests, and 9 of 200 tested positive. A total of 177 DPTs were performed with amoxicillin for 5 days in each child. Diagnosis of amoxicillin allergy was confirmed by a DPT in 17 patients (9.6%); 14/17 had history of nonimmediate reactions; 4/14 (26.6%) reacted on day 5.

CONCLUSION

According to our results, a long-term DPT protocol increases the sensitivity of the allergy work-up, and it should be recommended for patients with a history of amoxicillin nonimmediate reaction.

Azithromycin is more allergenic than clarithromycin in children with suspected hypersensitivity reaction to macrolides

BACKGROUND

Macrolides are considered safe antibiotics with reduced allergenic activity. However, studies on the safety of macrolides are scarce, particularly in children.

OBJECTIVE

The aim of this study was to assess the frequency of hypersensitivity reactions to clarithromycin and azithromycin in a group of children referred to our allergy unit for suspected macrolide allergy.

METHODS

We retrospectively reviewed the charts of 90 children aged 1-17 years with symptoms suggestive of hypersensitivity reaction to clarithromycin or azithromycin between December 31, 2008 and December 31, 2013. The allergy workup included skin tests (ie, skin prick tests and/or intradermal tests), determination of serum specific IgE (sIgE) to clarithromycin and azithromycin, and, if necessary to reach a diagnosis, oral provocation tests.

RESULTS

Seventy-seven children completed the allergy workup. A reaction to clarithromycin was recorded in 58 children (75.3%): 21 (36.2%) had a history of immediate reactions, and 37 (63.8%) had a history of nonimmediate reactions. A reaction to azithromycin was recorded in 19 children (24.6%): 6 (31.5%) had a history of immediate reaction, and 13 (68.42%) had a history of nonimmediate reaction. Positive results in skin tests and oral provocation tests with the suspect drug confirmed the diagnosis in 15.5% of reactions to clarithromycin (9 of 58) and in 47.3% of reactions to azithromycin (9 of 19) (P = .004).

CONCLUSION

A complete allergy workup enabled us to confirm a diagnosis of clarithromycin and azithromycin allergy in 15.5% and 47.3% of cases, respectively. Azithromycin was more allergenic than clarithromycin in children.

Management of acute rhinosinusitis

Acute rhinosinusitis (ARS) is one of the most common reasons for physician visits and for significant school absenteeism, although precise data on its prevalence and incidence are still lacking. RS is defined as acute if there are symptoms lasting <12 wk with complete resolution. Superinfection by bacteria following a viral infection is the most important mechanism of ARS. Diagnosis of ARS should be made on clinical grounds alone. Typically, acute bacterial RS is self-limited and goes through spontaneous recovery within 4 wk. Recognizing the occurrence of bacterial superinfections of the sinuses during a common viral respiratory infection is fundamental to making the decision to start an appropriate antibiotic treatment. Topical treatments such as saline irrigation, nasal decongestants, steroids, antihistamines, and fungicides are all in widespread pediatric use, but analyzing the literature gives poor evidence of efficacy, except for topical steroids. RS is a multifactorial condition that poses a diagnostic and management challenge to infectivologist and ear-nose-throat specialists as well as to pediatricians.

Correlation of anti-Pru p 3 IgE levels with severity of peach allergy reactions in children

BACKGROUND

Peach allergy is regarded as one of the most important fresh fruit allergies. Data are available on the state-of-the-art diagnosis, including food challenges, and a component-resolved diagnosis. However, the roles played by different peach allergens with respect to symptom severity are not completely understood.

OBJECTIVE

To evaluate the role of serum specific IgE to peach and recombinant allergens in the diagnosis of peach allergies in Italian children.

METHODS

Forty-four children with peach allergy confirmed by a placebo-controlled food challenge were divided into 2 groups based on their symptom severity: patients with mild oral allergy syndrome (OAS) and patients with systemic symptoms (SS). The presence of specific IgE to peach and rPru p 1, rPru p 3, and rPru p 4 was determined.

RESULTS

The presence of specific IgE to Pru p 4 and Pru p 1 was found significantly more frequently in patients with OAS, whereas specific IgE to Pru p 3 was not found significantly more frequently in patients with SS. Only anti-rPru p 4 IgE levels were significantly higher in patients with OAS, whereas no significant differences were found in anti-rPru p 1 and anti-rPru p 3 IgE levels between patients with OAS compared with patients with SS.

CONCLUSION

In Italian children with peach allergies, the presence of specific IgE to Pru p 3 is not associated with SS, and the levels of specific IgE to Pru p 3 do not correlate with the severity of the reactions.

Oral desensitization to milk: how to choose the starting dose!

A renewed interest in oral desensitization as treatment for food allergy has been observed in the last few years. We studied a novel method based on the end point skin prick test procedure to establish the starting dose for oral desensitization in a group of 30 children highly allergic to milk. The results (in terms of reactions to the first dose administered) were compared with a group of 20 children allergic to milk as well. Such control group started to swallow the same dose of 0.015 mg/ml of milk. None reacted to the first dose when administered according to the end point skin prick test. On the other side, ten out of 20 children (50%) from the control group showed mild allergic reactions to the first dose of milk. In conclusion the end point skin prick test procedure results safe and easy to be performed in each single child in order to find out the starting dose for oral desensitization to milk, also by taking into account the individual variability.

Upper airways disease: role of corticosteroids

Nasal topical steroids (INCSs) are well established effective therapy in allergic rhinitis both in children and adults. There is clear benefit in using INCSs over antihistamines in allergic rhinitis while short courses of oral corticosteroids (CSs) may be indicated in severe cases. The addition of INCSs to oral antibiotics has been proven to be more effective than antibiotics alone for achieving symptomatic improvement in patients with acute rhino sinusitis. INCSs as monotherapy are also effective in the treatment of allergic rhinosinusitis (ARS). Several randomized controlled trials have evaluated the role of INCSs in chronic RS with the majority demonstrating a beneficial effect. In adults, the clinical efficacy of oral corticosteroids in the management of chronic RS with nasal polyposis is well established. There are no randomized controlled trials evaluating the efficacy of systemic CSs in chronic RS without nasal polyposis.

Allergen specific nasal challenge to latex in children with latex allergy: clinical and immunological evaluation

There are no data concerning the significance of allergen specific nasal challenge to latex (ASNCL) in the pediatric population and the effect of mometasone furoate nasal spray (MFNS), topic corticosteroid exerting a potent anti-inflammatory activity in children with latex allergic rhinitis. The aims of this study are: to investigate the clinical and immune pathological effects of ASNCL in children with latex allergy; to study the effects of MFNS pre-medication on the clinical and immune pathological effects of ASNCL in children with latex allergy. Thirteen children: 6 male and 7 female, mean (SD) age 9.6 (2.9) years, with latex allergy and seven children: 3 male and 4 female, mean (SD) age 9.9 (3.8) years, without latex allergy underwent ASNCL. Nasal symptoms were recorded, nasal lavage fluid was collected to measure tryptase, eosinophil cationic protein (ECP), interleukin-5, interferon-gamma levels, and spirometric test was performed for each patient without or with premedication with MFNS. ASNCL induced a clinical allergic response and increased tryptase levels only in children with latex allergy. No serious adverse events occurred after ASNCL. MFNS premedication reduced both tryptase and ECP levels only in children with latex allergy. ASNCL is a simple, reliable and useful tool to make or confirm the diagnosis of nasal symptoms due to latex; it allows us to study both clinical symptoms and local immunological changes. MFNS premedication before an ASNCL may prevent some immunological responses induced by ASNCL without clinical allergic modifications.

Lack of transmission of TT virus through immunoglobulins

BACKGROUND

A high prevalence of TT virus (TTV) infection has been found in patients who received blood or blood components. Viral DNA was demonstrated in commercial preparations of FVIII and F IX, but very few data have been reported on immunoglobulins. The risk of TTV infection associated with intramuscular or IV immunoglobulin administration is unclear.

STUDY DESIGN AND METHODS

The prevalence of TTV infection in a group of patients undergoing lifelong therapy because of congenital immunodeficiency has been evaluated in a long term follow-up (median, 6 years). Seventeen patients with congenital immunodeficiency receiving monthly administration of IVIG were included in the study. TTV DNA was repeatedly evaluated by PCR in serum samples from each patient during the follow-up. Research of antibodies against TTV was not applicable, as the patients studied were unable to produce antibodies. The presence of TTV was also evaluated in 15 IVIG lots.

RESULTS

The total amount of immunoglobulin administered was 18,773 g. TTV infection was not found in any patients included in the study. None of the 15 immunoglobulin preparations analyzed was found positive for TTV DNA.

CONCLUSION

Despite the high prevalence of TTV in blood donors, commercial immunoglobulins are safe and unable to transmit TTV.

[Pseudoallergies]

Pseudo-allergic-reactions (PAR) are clinical manifestations including urticaria, angioedema, conjunctivitis, rhinitis, asthma, and anaphylaxis. The prevalence of PAR ranges from 0.1% to 75% according to various studies. The pathogenetic mechanism of these diseases is not immunologically mediated. Food, additives, and drugs are the main responsibilities for PAR. The diagnosis of PAR is characterized by the absence of specific IgE for the suspected products. The absence of immunological mechanisms is confirmed by in vitro and in vivo tests. The treatment of PAR is similar to that of allergic diseases (antihistamine drugs, steroids, B2 agonists, epinephrine).

Inhibition of natural killer cell cytotoxicity and interferon gamma production by the envelope protein of HIV and prevention by vasoactive intestinal peptide

Natural killer (NK) cell dysfunction is common in human immunodeficiency virus (HIV)-infected subjects, although its mechanisms are poorly understood. A direct effect of HIV envelope glycoprotein gp120 may be involved. We investigated the in vitro effects of gp120 on the major NK cell effector functions, natural cytotoxicity and cytokine production. In addition, the ability of the vasoactive intestinal peptide (VIP) to modulate these effects was investigated. Our results indicated that gp120 inhibits NK natural cytotoxicity and showed, for the first time, that the inhibition affects also the production of the proinflammatory cytokine interferon-gamma (IFN-gamma). Interestingly, the inhibitory effect on NK cell functions was obtained with gp120 at concentrations within the range measured in the serum of HIV-infected subjects. Furthermore, we showed that the inhibitory activity of gp120 can be prevented by coincubation with VIP, even if VIP has no stimulatory activity by itself. Taken together these data suggest that (1) an inhibitory effect of gp120 may account for the NK cell dysfunction in HIV-infected subjects; (2) the gp120-mediated decrease in IFN-gamma production by NK cells may contribute to the cytokine imbalance observed in HIV infection; and (3) VIP counteracts the inhibitory effect of gp120 on NK cell functions.

Interleukin-6 release by cultured peripheral blood mononuclear cells inversely correlates with height velocity, bone age, insulin-like growth factor-I, and insulin-like growth factor binding protein-3 serum levels in children with perinatal HIV-1 infection

Spontaneous and phytohemagglutinin (PHA)-stimulated interleukin (IL)-6 release by cultured peripheral blood mononuclear cells was related to height velocity, bone age, insulin-like growth factor-I (IGF-I), and IGF binding protein-3 (IGFBP-3) serum level standard deviation scores (SDS) of 32 children [aged 91 (median; range 13-151) months] with human immunodeficiency virus-type 1 (HIV-1) perinatal infection and severe disease. Spontaneous and PHA-stimulated IL-6 release inversely correlated with height velocity, bone age, IGF-I, and IGFBP-3 SDS. Ten children with height velocity SDS </= -2, compared to 22 children with height velocity SDS > -2, showed higher spontaneous and PHA-stimulated IL-6 release and lower IGF-I and IGFBP-3 SDS (irrespective of CD4-positive T-lymphocyte counts, viral load, liver disease, or nutrition status). IL-6 overproduction may be a mechanism of IGF-I and IGFBP-3 down-regulation and impaired linear growth in children with perinatal HIV-1 infection. Growth-promoting strategies, including targeted anticytokine treatments, could be devised for such children.

Viral load and CD69 molecule expression on freshly isolated and cultured mitogen-stimulated lymphocytes of children with perinatal HIV-1 infection

HIV-1 in adults changes the proportion of mitogen-stimulated lymphocytes expressing the CD69 activation molecule, but little is known about this molecule expression on lymphocytes of HIV-1-infected (HIV-1+) children. Freshly isolated CD3+, CD4+, CD8+ and CD19+ and phytohaemagglutinin (PHA)-stimulated CD3+, CD4+ and CD8+ lymphocytes co-expressing CD69 were investigated cross-sectionally (adopting a MoAb double-staining technique) in 24 HIV-1+ children with severe disease and given anti-retroviral therapy and in 24 age-matched healthy children. CD69 results in HIV-1+ children were correlated with plasma HIV-1 RNA load prospectively determined. HIV-1+ compared with healthy children had higher frequencies of freshly isolated CD3+CD69+ (2.4 +/- 2.2% versus 0.9 +/- 0.5%; P = 0.002) and CD8+CD69+ (1.5 +/- 1.1% versus 0. 5 +/- 0.2%; P < 0.0001) lymphocytes. The frequencies of CD4+CD69+ and CD19+CD69+ lymphocytes were similar. High viral load correlated with an elevated proportion of freshly isolated CD3+CD69+ and CD8+CD69+ lymphocytes. HIV-1+ children showed reduced frequencies of PHA-stimulated CD3+CD69+ (60.7 +/- 7.6% versus 86.1 +/- 7.6%; P < 0. 001), CD4+CD69+ (73.6 +/- 18.2% versus 92.6 +/- 5.1%; P < 0.001), and CD8+CD69+ (51.0 +/- 19.1% versus 65.3 +/- 15.4%; P = 0.007) lymphocytes. Virologic worsening within 6 months correlated with a low proportion of PHA-stimulated CD3+CD69+ and CD8+CD69+ lymphocytes. CD69 molecule expression reflected the coexistence of immune activation and immune deficiency in HIV-1 infection. Changes partly differed from those observed in HIV-1+ adults. CD8+CD69+ (but not CD4+CD69+) lymphocyte proportion correlated with virologic course, and an impaired ability of CD8+ lymphocytes to express CD69 upon PHA stimulation preceded a virologic worsening.

Low IgG3 and high IgG4 subclass levels in children with advanced human immunodeficiency virus-type 1 infection and elevated IgE levels

BACKGROUND

IgG3 and IgG4 levels are not always changed in children perinatally infected with human immunodeficiency virus-type 1 (HIV-1). Elevated IgE levels hallmark the TH1 to TH2 switch occurring in advanced infection and such an unbalanced cytokine network may affect the IgG subclass production.

OBJECTIVE

To examine the different behaviour of IgG3 and IgG4 in the light of elevated IgE levels.

METHODS

IgE and IgG subclass levels were cross-sectionally determined (by radioimmunoassay and enzyme-linked immunosorbent assay, respectively) in 54 HIV-1 perinatally infected children. IgE levels beyond the upper 95% confidence limits (95%CL) of the age-related reference values defined elevated IgE levels. Since immunoglobulin levels physiologically vary with age, individual z-scores of isotype levels were calculated using the upper 95%CL of age-related reference values.

RESULTS

Fifteen (27.7%) children had elevated IgE levels. They had lower IgG3 (mean +/- standard deviation: -1.4+/-0.9 versus 6.9+/-0.9; P < .0001) and higher IgG4 (3.1+/-0.6 versus 0.2+/-0.3; P < .0001) z-scores compared with children without elevated IgE levels. Similar IgG1 (11.7+/-1.8 versus 12.6+/-1.3) and IgG2 (-0.22+/-0.8 versus -0.19+/-0.6) z-scores were found. In children with elevated IgE levels, IgE and IgG3 z-scores inversely correlated (r = -0.867; P < .0001), IgE and IgG4 z-scores directly correlated (r = 0.831; P < .0001) and IgG3 and IgG4 z-scores inversely correlated (r = -0.745; P < .001).

CONCLUSION

Low IgG3 and high IgG4 levels may be present in HIV-1 advanced disease with elevated IgE levels. Changes may be in line with the TH1 to TH2 switch and contribute to disease progression.

Interleukin-6 synthesis and IgE overproduction in children with perinatal human immunodeficiency virus-type 1 infection

BACKGROUND

Unbalanced interleukin network and elevated IL-6 synthesis are suggested mechanisms of immunoglobulin overproduction in children with perinatal human immunodeficiency virus-type 1 (HIV-1) infection.

OBJECTIVE

To investigate whether elevated IL-6 synthesis is a general mechanism of immunoglobulin overproduction in perinatal HIV-1 infection.

METHODS

In vitro spontaneous and phytohaemoagglutinin (PHA)-stimulated IL-6 and IL-2 synthesis, serum IgE, IgG, IgA, and IgM levels, CD4+ T-lymphocyte counts, and HIV-1 RNA copy numbers were cross-sectionally determined in 31 children with perinatal HIV-1 infection. Children with immunoglobulin z-scores in the highest quartile were defined as children with high immunoglobulin level. Relationships between interleukin synthesis, high immunoglobulin levels, and HIV-1 related disease were studied.

RESULTS

Children with high IgE levels had higher spontaneous IL-6 synthesis (1337 +/- 138 pg/mL) compared with those without high IgE levels (861 +/- 194 pg/mL; P < .001). By contrast, spontaneous IL-6 synthesis was similar in children with or without high IgG, IgA, or IgM levels. Decreased PHA-stimulated IL-2 synthesis, low CD4+ lymphocyte counts, elevated HIV-1 RNA copy numbers, and severe disease correlated with high IgE (but not IgG, IgA, and IgM) levels. IgG, IgA, and IgM levels correlated with each other, but not with IgE levels.

CONCLUSION

The increased IL-6 synthesis in HIV-1+ children may affect IgE rather than other immunoglobulin isotype levels. Overall results suggest that IgE and IgG, IgA, IgM overproduction have distinct underlying mechanisms.

Hepatitis G virus infection in human immunodeficiency virus type 1-infected mothers and their children

Hepatitis G virus (HGV) RNA and anti-E2 glycoprotein antibody (E2Ab) seroprevalence was studied in 58 human immunodeficiency virus type 1 (HIV-1)-infected mothers (34 injecting drug users [IDUs] and 24 with risky sexual behavior [RSB]) and their children (median age, 5 days; range, 1-27). Twelve women (20.6%) were RNA- and 20 (34.4%) E2Ab-positive. Seroprevalence was similar in the IDU and RSB groups and high in RSB partners of IDU men. Five (41.6%) children of RNA-positive mothers were HGV-infected, at a median age of 5 days (range, 1-27), independent of maternal CD4 T lymphocyte numbers, mode of delivery, and HIV-1 transmission; no other child at risk became RNA-positive subsequently. No HGV-infected child (follow-up, 16 months; range, 12-52) showed increased liver enzyme levels; 3 children cleared RNA and E2Ab-seroconverted after 10-48 months. Thus, in HIV-1-infected women, HGV infection is common and also sexually transmitted, and clearance may be impaired. Mother-to-child transmission is frequent and occurs antenatally; children remain long infected without evident disease.

Different meaning of CD38 molecule expression on CD4+ and CD8+ cells of children perinatally infected with human immunodeficiency virus type 1 infection surviving longer than five years

We investigated the relationship between CD4+CD38+, CD4+HLA-DR+, CD8+CD38+, and CD8+HLA-DR+ cell proportions (HLA-DR = major histocompatibility complex class II) (determined by two-color immunofluorescence) and the clinical condition, IL-2 and IL-6 production, viral RNA copy numbers, and the eventual immunologic-virologic course in 25 children perinatally infected with HIV-1 surviving longer than 5 y [median age, 92 (range, 63-136) mo]. Twelve healthy age-matched children were studied as control subjects. HIV-1+ children had lower percentages and absolute numbers of CD4+CD38+, whereas the percentages of CD4+HLA-DR+ and the percentages and absolute numbers of CD8+CD38+ and CD8+HLA-DR+ cells were higher than that of control subjects. The absolute numbers of CD4+ and the percentages of CD4+CD38+, CD8+CD38+, and CD8+HLA-DR+ cells directly correlated, whereas the percentages of CD4+CD38+ and CD4+HLA-DR+ cells, the percentages of CD4+CD38+ and CD8+CD38+ cells, the CD8+ cell absolute numbers, and the percentages of CD8+CD38+ cells did not. Severe manifestations and immunologic deterioration occurred in children with low CD4+CD38+ cell percentages, whereas virologic worsening was associated with low CD8+CD38+ and CD8+HLA-DR+ cell percentages. IL-2 production directly correlated with percentages and absolute numbers of CD4+CD38+ and CD8+CD38+ cells. RNA copy numbers inversely correlated with CD4+CD38+, CD4+HLA-DR+, CD8+CD38+, and CD8+HLA-DR+ cell percentages. This suggests that CD38 molecule expression on both CD4+ and CD8+ cell subsets is a favorable marker in HIV-1+ children. Perhaps CD8+CD38+ subsets are activated cells, whereas CD4+CD38+ subsets are immature cells, possibly the host's attempt at CD4+ cell renewal.

Eosinophil cationic protein (ECP) and tryptase in the nasal lavage fluid (NLF) of children with grass pollen rhinitis: levocabastine effect

This study was carried out to determine the concentrations of eosinophil cationic protein (ECP) and tryptase in the nasal lavage fluid (NLF) of 24 children (C) with grass pollen rhinitis as well as rhinitis symptoms before and after nasal provocation tests with or without a levocabastine (anti-H1 topical antihistamine) pretreatment. All C were monosensitized to grasses only. Twelve patients (Active Group = AG) were tested with a nasal provocation test with grass pollen (NPT) carried out by the insufflation of increasingly higher doses of an allergenic extract powder, while the other 12 patients (Placebo Group = PG) underwent just a nasal provocation test with lactose (placebo) (NPTp). The prechallenge NLF, obtained both before (C) and after (AG) levocabastine pretreatment, was compared to that obtained after periods of 2 and 24 hours postchallenge. In the AG, before and after levocabastine pretreatment, the tryptase concentrations had not significantly increased, whereas the ECP concentrations were found to be significantly higher (p < 0.05) in just the 24-hour postchallenge samples. In the PG the rhinitis symptoms were not induced by the NPTp and there was no significant change in either ECP or tryptase concentrations. In the AG a levocabastine pretreatment induced a significant increase (p < 0.05) in the cumulative allergen doses administered by the NPT. There was a reduction of the nasal symptoms in 7 patients, while in 3 subjects there was only a slight improvement, but in 2 subjects no effect was encountered. In conclusion this study shows that a levocabastine pretreatment before an NPT in patients with grass pollen rhinitis, outside the grass pollen season, induces a significant increase in the cumulative allergen doses (administered by the NPT) which provoked rhinitis symptoms but is not able to demonstrate any significant reduction in the ECP concentrations of the NLF.

Skin diseases in immigrants seen as out-patients in the Institute of Dermatology of the University of Rome 'La Sapienza' from 1989 to 1994

In the Institute of Dermatology of the University of Rome 'La Sapienza' (IDURLS) from 1989 to 1994, 2198 immigrants from countries outside the European Community were seen as out-patients. Their personal and pathological data were collected by a particular software 'Questio', set up together with colleagues of the Interdepartimental Center for Scientific Calculous (ICSC) of the University of Rome 'La Sapienza'. The number of patients has been increasing from 326 in 1989 to 436 in 1994. Most of the people were coming from Africa, but from 1989 to 1994 the number of patients from the regions of ex-Yugoslavia has been increasing. About one third of the immigrants were unemployed, whereas 40% of them had a job (worker or employee), and the remaining 20% was composed by students and housewives. Most immigrants (1474 patients) were 20-39-year-old. Their data were compared with those of a control group composed by 2100 Italian people of the same age and sex, seen as out-patients in IDURLS in the same period. The most frequent skin disorders observed in immigrants were skin infectious or parasitic diseases, above all scabies. Excluding people with scabies, both immigrants and Italian patients shared the same skin diseases typical of young adult people: many fungal infections, many contact dermatitis and very few skin malignant tumors.

Ten-year follow-up study of neonatal hepatitis B immunization: are booster injections indicated?

One hundred and fourteen children, born to HBsAg-positive mothers received in the first year of life passive active prophylaxis for hepatitis B virus (HBV). They have been followed up to 10 years. A booster dose given in a cohort at the 5th year does not seem to increase protection against HBV. No difference in immunological memory was present at the 10th year between the group of children who had received the booster dose at 5 years of age and the group who did not.

Acellular pertussis vaccine in children with perinatal human immunodeficiency virus-type 1 infection

The immunogenicity of an acellular pertussis vaccine containing genetically detoxified pertussis toxin, filamentous haemoagglutinin and pertactin was studied in 12 children [median age: 45 (6-107) months] with perinatal human immunodeficiency virus-type 1 (HIV-1) infection. Antibody response to all antigens was observed in six cases and another children 3 reacted to two or one antigen(s), but titres were lower than those from healthy controls. Antibody titre fold-rise correlated with preimmunization CD4-positive cell counts. Significant titres were still detectable 4 months after the third dose. The acellular vaccine is immunogenic in a portion of children with perinatal HIV-1 infection but early vaccination might be more effective, taking advantage of still adequate CD4-positive cell numbers.

Does the classification system fit disease progression in perinatal human immunodeficiency virus infection?

The objective was to test the applicability of the new classification for paediatric human immonodeficiency virus infection. The person-time of each state, transition probabilities and survival (+/- standard errors) at 5 years, and median sojourn-time were calculated on 39 perinatally infected children followed up from the first month of life for a median of 64.5 (1.2-120.1) months. The person-times of the N2, N3, B1, C1, and C2 states were low. The transition probabilities and sojourn-times were similar for A (48.1 +/- 10.8%; 63.5 months), B (50.5 +/- 15.5%; 44.9 months) and C (74.6 +/- 15.1%; 43.1 months) clinical categories, which differed (p < 0.025) from the N category (87.9 +/- 5.5%; 12.05 months). The survival probabilities after 5 years of entering the A, B and C categories were 84.8 +/- 10.7%, 60.5 +/- 19.8% and 14.8 +/- 13.5%, respectively (p < 0.001). Immunological category 3 had lower transition probabilities and longer sojourn-times (58.8 +/- 16.6%; 53.3 months) than categories 1 (71.3 +/- 8.1%; 33.2 months) and 2 (75.6 +/- 10.5%; 19.8 months) (p < 0.01). The transition probabilities to C3 for states N3, A3 or B3 were 52.5 +/- 13.5%. In conclusion, the classification fits the clinical history better than the immunological history.

Hemochrome parameters during the first two years of life in children with perinatal HIV-1 infection

Monthly hemochrome parameters were obtained during the first 2 years of age in 22 children with perinatal human immunodeficiency virus type-1 (HIV-1) infection and in 58 exposed seroreverted children. Timing and predictive value of hemochrome modifications were investigated. Exclusion criteria were hemoglobinopathies and zidovudine (AZT) treatment in pregnancy. When AZT treatment was undertaken children were eliminated from the study. From the second month of life red blood cell (RBC) counts, hemoglobin (Hb) concentrations, and hematocrit values were significantly lower in infected than in uninfected children. RBC counts progressively diverged in infected and uninfected children, and mean values in the former group never reached 4.10(12)/L. No difference was observed in Hb content ratios and RBC size parameters. At 2 months RBC counts, Hb concentrations, and hematocrit values below reference values were associated with a 15.8 (95% confidence limits [CL]: 5.5-48.8) relative risk of being infected. In infected infants aged 5 months a decrease in these parameters was associated with an 11.2 (95% CL: 1.6-77.8) relative risk of developing eventual severe clinical outcome. Low RBC counts, Hb concentrations, and hematocrit values may be included among predictive criteria in infants of HIV-1 infected mothers.

Mother-to-infant transmission of hepatitis C virus

Anti-hepatitis C virus (HCV) antibodies and HCV-RNA were measured in the sera of 22 anti-HCV positive, HIV-1 negative mothers and their infants. ELISA and RIBA II were used for anti-HCV determination. HCV-RNA was measured by a nested polymerase chain reaction. HCV-RNA was found in 12 of 22 mothers. All 22 children were followed for 12 months. All were anti-HCV positive by the fourth month; 18 became anti-HCV negative between the 8th and 12th month. HCV-RNA was detected in 5 of 22 infants in the fourth month. They remained HCV-RNA positive. All children born to HCV-RNA negative mothers were HCV-RNA negative while 5 of 12 babies born to HCV-RNA positive mothers were infected. All five infected babies were born to mothers infected through transfusions or drug use. ALT levels in mothers seemed to have no effect on mother-to-infant transmission. Hence evidence for perinatal transmission of HCV from HCV-RNA positive mothers was demonstrated in the present study.

High levels of IgA in HIV-1-perinatally-infected children. Antigen specificity and possible role of increased substance P plasma levels

The specificity of IgA against food, inhalant, bacterial and fungine antigens as well as for HIV-1 proteins was investigated in 14 HIV-1-infected children (CDC stage P-2) and 15 controls. IgA against food- and inhalant antigens as well as against tetanus toxoid were significantly more often present in the HIV positive children than in controls. No difference between the two groups was present for IgA against Candida albicans. A significant increase of substance P, a strong IgA synthesis inducing neuropeptide, was demonstrated in the plasma of HIV-1 infected children. In conclusion, high levels of IgA seem to reflect a complex immune dysfunction in which many factors are involved. The importance of neuroimmune dysregulation is discussed.

Pathogenesis of posttransfusion viral hepatitis in children with beta-thalassemia

The pathogenesis of posttransfusion hepatitis was determined in 14 children with beta-thalassemia. All had blood samples obtained in 1980 or 1981, were vaccinated against hepatitis B virus in 1983 and had another serum sample collected in 1989. Seven children had detectable antibodies against hepatitis C virus before vaccination, and all were positive in 1989. With specific solid-phase enzyme immunoassays, all children had antibodies against hepatitis B virus, X and polymerase antigens in 1981, and six had one or both antibodies in 1989. Hepatitis B virus infection was confirmed by means of polymerase chain reaction, which demonstrated virus DNA in 13 of the 14 children. The amplification products spanning the X/precore region were smaller than expected, suggesting mutations in this region. Cloning and sequencing of these products revealed deletions spanning part or all of the X gene. The results show that these children were infected with hepatitis B virus even without other markers in serum, that hepatitis B persists years after vaccination and that such infections are associated with the presence of X deletion mutants. Coinfection with hepatitis B and C viruses, the former containing a new class of variants, is common in children with beta-thalassemia.

Impaired superoxide anion, platelet-activating factor, and leukotriene B4 synthesis by neutrophils in cirrhosis

BACKGROUND

Several alterations of polymorphonuclear leukocyte (PMN) function were found in alcoholic cirrhotics that may contribute to augmented susceptibility to infections. We evaluated function and synthesis of lipid mediators in PMN obtained from nonalcoholic cirrhotics.

METHODS

We evaluated the phagocytic and chemotactic response together with superoxide anion (O2-), leukotriene B4, (LTB4) and platelet-activating factor (PAF) production in response to different stimuli in PMN from nonalcoholic cirrhotics as compared with controls.

RESULTS

PMN from cirrhotics showed, after stimulation with opsonized zymosan (STZ) and phorbol-12-myristate-13-acetate, a reduced capacity to produce O2- when compared with controls. [3H]acetate incorporation into PAF was significantly higher in PMN obtained from controls in respect to cirrhotics. Gas chromatography/mass spectrometry analysis confirmed a reduced PAF synthesis by PMN obtained from cirrhotics. LTB4 production from PMN, after stimulation with calcium ionophore (A23187) and STZ, was significantly reduced in cirrhotics. [3H]arachidonic acid release from prelabeled PMN, measured upon stimulation with A23187 and STZ, was higher in controls than in cirrhotics.

CONCLUSIONS

An altered synthesis of LTB4 and PAF is associated with an impaired O2- production by PMN in nonalcoholic cirrhosis. Reduced synthesis of lipid mediators may be related to an altered phospholipase A, activity.

[Reduced natural killer function in children with recurrent respiratory tract infections]

Respiratory infections are the major cause of disease in childhood in the industrialized areas of the world. This essentially depends on two factors: immunological immaturity and immunological naivety. In most cases a virus has been considered the causative agent in respiratory infection. A defect in immune responses has been described in children with recurrent respiratory infections and in particular a decrease in CD4/CD8 T lymphocyte ratio or in IL-2 and IFN-gamma production. Our results show that Natural Killer (NK) cell activity is defective in children with recurrent respiratory infections. That is particularly noteworthy since NK cells play an important role in host defense against viral infections. At present it is difficult to understand whether the NK defect is a primary defect or it is secondary to viral infections. Further studies will help to clarify whether NK decreased activity depends on a cell damage directly caused by virus or it depends on the decreased levels of cytokines.

[IgG subclasses against bovine alpha-lactalbumin and beta-lactoglobulin in infants fed with a seroprotein hydrolysate]

Prevention of food allergy in infancy has been the aim of important researches in the last years but many studies have produced conflicting conclusions. The use of hydrolysate formulas seems to be an helpful tool in prevention of cow milk protein allergy but confusion often remains about capability of small hydrolysate molecules to be "allergens" or "antigens". In order to clarify this point IgE, IgG and IgM as well as IgG subclasses against alfa-lactoalbumin (ALA) and beta-lactoglobulin (BLG) have been evaluated in 41 infants at risk for allergy and in 30 controls at the fourth month. The same evaluation has been done on their mothers. The 41 "at risk" children were fed with breast milk or with an hypoallergenic formula (Nidina HA, Nestlè) or both. The control children received an adapted formula. No difference between the two groups of children was found regarding IgM or IgG against ALA while antibodies against BLG were more frequently found in controls than in "at risk" children. Only one child in the group fed with Nidina HA developed specific IgE against whole milk. Therefore hydrolysate formula seems to be as antigenic (not allergenic) as adapted formula in respect of ALA while BLG contained in adapted formula seems to be a stronger immunogen. The pattern of specific IgG subclasses against ALA and BLG is different between the two groups of children because of the absence in "at risk" group of specific IgG2 and IgG3. As for the mothers, the presence in their sera of IgG against ALA or BLG seems to induce in infants a reduced response to the same antigen.

[Hepatitis B virus: new markers and their immunology]

Hepatitis B virus (HBV) is one of the most important causes of chronic liver disease. HBV is a DNA virus with an external glycoprotein surface and an internal nucleocapsid which contains the viral genome. HBV infection is revealed by the appearance of specific markers. Some of these markers are well known and their presence in serum is important to understand the behaviour of the disease. Among them HBsAg, HBeAg, anti-HBs and anti-HBe are found in serum, so as anti-Core; the HBcAg may be found in hepatic tissue and marks infectivity and virus replication. In the few last years some new antigens and antibodies have been studied and their importance in diagnosis and follow-up of hepatitis has been recognized. HBxAg, Pre-S and DNA-Polymerase (Pol) seem to be specific and early signals of viral replication. More studies showed the trans-activating properties of HBxAg; actually the X protein seems to be involved in replicative cycle of HBV. Many Authors also demonstrated a relationship between the presence of X in serum and/or liver and the progression of disease to cirrhosis and hepatocellular carcinoma. The Pol antigen and its antibody seem to be very common markers of HBV infection in serum of patients with hepatitis. Moreover their presence is the only signal of viral infection in some patients which have no other marker of HBV. More studies are of course needed to exactly establish the significance of these new markers and their importance for diagnosis and prognosis of HBV infection.

[Specific IgA against multiple antigens as expression of immunologic deregulation in HIV-positive children]

B-cell dysfunction in HIV-infected children is reflected by hypergammaglobulinemia and high levels of serum IgA. Little is known about antibody specificity since only a small portion of serum IgA appears to be directed against HIV proteins. In the present study the specificity of IgA antibodies against food, inhalant, bacterial and fungi antigens were evaluated in a population of HIV infected children. ELISA method was used for antibody testing. Our results show that in 84.6% of patients IgA against at least one food antigen are present. IgA against inhalant allergens were present in most of HIV-infected children but in none of controls. As for anti-tetanus toxoid antigens and anti-fungi antigens, though present in higher percentage in patients, specific IgA were found also in healthy children. If a gastrointestinal dysfunction might be supposed as the cause of presence of anti-food antigen IgA, it is difficult to consider this factor as the cause of presence of specific IgA directed against different antigens. It is possible to postulate that an immunologic dysregulation based on an imbalance between Th1 and Th2 cells or on higher levels of IL-5 and/or IL-6 may lead to a misfunction of B cell and consequently to hypergammaglobulinemia with high IgA levels.

[Changed levels of substance P and somatostatin in HIV-positive children]

Substance P (sP) and Somatostatin (SOM), so as other neuropeptides can modulate neurologic and immunologic functions. sP has been described to enhance both in vitro and in vivo immunoglobulin synthesis. On the contrary, SOM has an inhibitory effect on the same activity. The modulating effect is more evident on IgA isotype. Hypergammaglobulinemia and in particular high levels of IgA is a common finding in pediatric AIDS and an imbalance among regulatory effects of neuropeptides might be suggested. In order to evaluate the plasma levels of sP in pediatric AIDS we studied 15 children with HIV infection (status P2), 10 seronegative children born to HIV positive mothers and 10 healthy children of the same age. All the HIV positive children had high plasma levels of IgG and IgA. The plasma level of sP was extremely higher in HIV positive children while no significant difference was found between seronegative children born to HIV positive mothers and healthy children. SOM was decreased in HIV positive children when compared to control groups but a significant difference was not reached. It might be supposed that HIV infection, through a dysregulation among neuropeptides interferes on immune functions and in particular on IgA synthesis. On the other hand it might be suggested that the imbalance between sP and SOM depends on the viral infection of immune cells since it has been demonstrated that SOM and other neuropeptide are synthesized by lymphoid tissue. Further studied relevance of neuropeptide disorders in pediatric AIDS.

Hepatitis C virus antibodies in a long-term follow-up of beta-thalassaemic children with acute and chronic non-A non-B hepatitis

The presence of antibodies toward hepatitis C virus (HCV) was examined in 78 polytransfused beta-thalassaemic children. The anti-HCV status was correlated with acute and chronic non-A non-B (NANB) hepatitis that developed during a follow up of about 13 years. Anti-HCV was present in 83.3% of children with acute NANB hepatitis and in 82.9% of those with chronic NANB hepatitis. The percentage of chronic evolution was 56.7% for acute anti-HCV positive NANB hepatitis and 50.0% for anti-HCV negative NANB hepatitis. The long-term persistence of anti-HCV antibodies did not correlate with chronic evolution of liver infection in thalassaemic patients. Histological features of chronic hepatitis showed little or no difference between HCV associated or non-associated liver disease. The multifactorial liver injury in beta-thalassaemic children explains the high prevalence of cirrhosis (about 30%) observed in these patients with NANB hepatitis. On the other hand, independent of liver disease, some patients never seroconverted during the follow up in spite of the high number of transfusions suggesting the existence of "non-responders".

VIP restores natural killer cell activity depressed by hepatitis B surface antigen

Vasoactive intestinal peptide (VIP) has recently been shown to bind to human lymphocytes and modulate immune functions. The ability of VIP in restoring natural killer (NK) cell activity depressed by hepatitis B surface antigen (HBsAg) has been investigated in the present research. Human lymphocytes were incubated with HBsAg and, after washing, a 4-hr cytotoxicity assay was performed. VIP was coincubated with lymphocytes during the preincubation with HBsAg or, alternatively, throughout the cytotoxicity assay. The study revealed that VIP, either preincubated or coincubated in the 4-hr assay, strongly restores NK cell activity depressed by viral antigen. This is noteworthy considering that a number of lymphocyte modulators such as interferons fail in restoring viral-dependent NK cell activity depression. In contrast with previous reports, even when coincubated in the 4-hr assay, VIP is a strong activator of NK cell activity. Further studies will be required to understand which mechanisms are involved in the interrelation between VIP and NK cells during viral infections.

Five-year follow-up of vaccination against hepatitis B virus in newborns vaccinated with a reduced number of doses

The protective efficacy and long-term immunogenicity of a schedule with a reduced number of vaccinations in infants born to mothers positive for hepatitis B surface antigen (HBsAg) has been investigated: 494 infants immunized with a plasma derived hepatitis B vaccine (Hevac B Pasteur) at day 20 after birth and 2 months later were studied. Anti-HBs seroconversion rate was 96% after the second dose, a value similar to that obtained in older children. At 5 years of life anti-HBs at protective levels was still 95.8%. In conclusion, we suggest that this effective and economical reduced vaccination schedule, which before this study was applied to older children, can be used in newborns from HBsAg positive mothers with good protective efficacy shifting the beginning of active immunization from birth to day 20.

False diagnosis of non-A/non-B hepatitis hiding two cases of cystic fibrosis

We report two cases of children followed for many years with an original diagnosis of non-A/non-B hepatitis. One child developed serious cirrhosis with portal hypertension. Long-term observation of the course of their hepatic disease provided the diagnosis of cystic fibrosis. These cases demonstrate that cystic fibrosis though rarely presenting with initial hepatic signs, can manifest itself with only long-term hepatic symptoms. We therefore strongly recommend analysis of sweat chloride concentration in cases of hepatic disease of unknown origin.

Permeability characteristics of deoxygenated sickle cells

This study investigated the effect of acute deoxygenation on membrane permeability characteristics of sickle cells. Measured fluxes of Na+ and K+ in ouabain-inhibited cells, of chloride and sulfate exchange in 4,4'-diisothiocyanostilbene-2,2'-disulfonate (DIDS)-inhibited and untreated cells, and of erythritol, mannitol, and arabinose in cytochalasin B-inhibited cells indicated that a deoxygenation-induced permeability change occurred in sickle cells only for cations and chloride. Monovalent cation permeabilities increased five-fold, and chloride influx into DIDS treated cells was enhanced nearly threefold on sickle cell deoxygenation. In contrast, no detectable increase in permeability to the other solutes was found. To gain perspective on these findings, similar measurements were performed in normal cells treated with diamide, an agent shown by others to induce a coupled increase in membrane permeability and phospholipid translocation, reminiscent of deoxygenation-induced changes in sickle cells. Although the increase in cation permeability was no greater than that in sickled cells, treatment with 2 mmol/L diamide also produced a twofold increase in the first order rate constants for sulfate exchange and mannitol efflux, indicating a relatively nonselective permeability increase that permitted flux of larger solutes than in the case of deoxygenated sickle cells. These results suggest that the deoxygenation of sickle cells induces a permeability increase that is relatively insensitive to charge, but is restrictive with respect to solute size.

Modulation by human milk of IgG subclass response to hepatitis B vaccine in infants

The influence of breast and formula feeding on specific anti-hepatitis B surface antigen (HBsAg) IgG subclass production and distribution has been investigated in 40 healthy infants, born to HBsAg-positive mothers and vaccinated against hepatitis B virus (HBV). Twenty children were bottle fed and 20 were breast fed. Specific subclasses were detected at the 4th and 12th months using an enzyme-linked immunosorbent assay with monoclonal antibodies. A defect in total IgG and IgG subclasses was previously excluded. Significant differences were observed both at the 4th and 12th months for IgG1 and IgG2. Breast-fed infants had significantly higher levels of specific IgG2 (about three times higher), while IgG1 levels were significantly higher in formula-fed infants. Anti-HBsAg IgG4 levels were always higher in bottle-fed infants, but a statistical significance was never present. No difference was found in specific IgG3 levels. This study reports the evidence that breast feeding influences specific IgG subclass synthesis against a viral antigen and suggests an immunologic modulation of the response to vaccines dependent not only on age but also on factors present in human milk.