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| CASE REPORT |
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| Year : 2014 | Volume
: 28
| Issue : 2 | Page : 103-106 |
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Allergies - Changes over time
Dilip Vishnu Maydeo
Department of Chest Diseases, Karamshi Jethabhai Somaiya Medical College, Mumbai, Maharashtra, India
| Date of Web Publication | 15-Sep-2014 |
Correspondence Address:
Dilip Vishnu Maydeo
Department of Chest Diseases, Karamshi Jethabhai Somaiya Medical College, Mumbai - 400 016, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0972-6691.140793
15 years old youth with upper and lower airway symptoms for 5 years underwent Allergy Testing in September 1985 and was detected to be having polysensitizations. He was desensitized in 1990 for 6 months to achieve satisfactory control for more than 20 years. He reported back with recurrence and underwent repeat allergy testing in July 2013. He demonstrated evidence of protection by desensitization to Holoptelia, Lawsonia, Aspergillus Tamari and Cladosporium even after more than 25 years. However newer allergies developed to Acacia, Adathoda, Rumex, A.Fumigatus, Ration Shop Dust, insects including House dust Mite, non-vegetarian food items as Beef, Mutton, Chicken, Prawn and vegetarian food item Pea. His sensitivity to Ant, Rice had remained status quo. Keywords: Bronchial asthma, intradermal skin tests, subcutaneous immunotherapy
How to cite this article:
Maydeo DV. Allergies - Changes over time. Indian J Allergy Asthma Immunol 2014;28:103-6 |
| Introduction | |  |
FS a young Muslim boy of 15 years residing in North Mumbai suburb was first seen on 5th April 1985 for nasal symptoms and breathlessness which he was having since 5 years and was taking treatment from a local general practitioner who referred him for further management and achieving control .There was a family history of Asthma in father who had developed symptoms of late. His father was a smoker, smoking 20 cigarettes per day.
Clinically, the patient appeared well-nourished and stable. His blood pressure and electrocardiogram (ECG) were normal. He had no positive findings except few scattered ronchi. Spirometry or peak expiratory flow rate (PEFR) was not done due to nonavailability. He was given oral bronchodilators and disodium chromoglycate nasal drops and asked to report after a week with blood tests and chest X ray. At follow up, although he had failed to undergo investigations, he was asymptomatic and without wheeze. He was prescribed disodium chromoglycate dry powder inhaler alone as a preventer twice daily and was advised to take adrenaline, atropine, and papaverine mixture inhalations through glass aerosol inhaler device as rescue medication on reappearance of symptoms. Inhalation route was accepted as a better route for fast action but newer molecules were in the process of being marketed as meter dose inhaler or dry powder inhaler formulations.
On 21 st May 1985 again, he reported with daytime symptoms and he was prescribed racemic salbutamol meter dose inhaler which had recently been introduced in the Indian market. During review after 3 weeks, he had to be reverted to oral bronchodilators and inhalations as rescue. In July 1985, he suffered from mild lower respiratory tract infection for which he was prescribed a course of antibiotic. Another successful attempt was made after a month to take him on inhaled and nasal disodium chromoglycate with salbutamol meter dose inhaler. In August, he was dewormed empirically with mebendazole and pyrantel pamoate.
He was then taken up for allergy testing in September 1985 as a control strategy with 60 pollens and fungi and food items by intradermal skin testing with allergens from Patel Chest Institute, Delhi. [1]
He was detected to have 4+ reactions to Holoptelia, Lawsonia, Cladosporium, House Dust, Cotton Dust, Aspergillus tamari, and Rice. He also developed 3+ Reactions to ant, butterfly, and moth. These gradations were as per D.N. Shivpuri criteria [Figure 1]. [2] He was advised to keep home environment free from pests and avoid Rice especially since he had noticed a relationship of exacerbation of symptoms with consumption of rice. Specific immunoglobulin E (IgE) for 4 + reactions were not done. He was not considered for immunotherapy for economic reasons. Specific desensitization was not contemplated as getting therapeutic allergens from Delhi and maintaining potency in transit and at home was difficult in those days. Total IgE or specific Ig was not done. He was told to avoid dusts, fumes, and gases in general. | Figure 1: Graph depicting PEFR Versus Date of patient with Spirometry and reversibility at two instances. Chart: Date versus peak expiratory flow rate/spirometry with two reversibility noting (The author thanks Mrs. Neha Kane-Maydeo for the technical support and Dr S.N. Gaur for encouragement and the patient for maintaining records for last 28 years)
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He was lost to follow-up till June 1990 when he reported mild recurrences since 1 year. He had started working for a chemical company from 1989. On closer questioning, he reported to be decreasingly controlled by salbutamol, a reliever and required courses of oral drugs, from his general practioner. He had predominantly nocturnal symptoms occurring in summer. He was now working at a Chemical Plant at Thane − Belapur region in suburban Mumbai. His PEFR was 270 improving to 370, post aerosol bronchodilator. His weight was 78 kg and his height as per record was 170 cms with a body mass index of 26.98. [3] This time he was put on a tapering course of oral steroids and inhaled bronchodilator followed by inhaled beclomethasone in form of dry powder inhaler. On 26 th June, his follow-up spirometry showed only small airway obstruction and he achieved a PEFR of 465 on Wright's mini PEFR meter as against 7.2 L/min on spirometry (432 l/s). Spirometry was done on indigenously designed spirometer (Medspiror of Recorders and Medicare, Chandigarh). His condition fluctuated requiring three repeated short courses of 7 days each of oral steroids, followed by inhaled beclomethasone diproprionate till Nov 1990.
It was then decided to desensitize him with specific aeroallergens mixture of six items totaling 5 mL with 0.5 mL each of Holoptelia and Lawsonia and 1 mL each of A. tamari, Cladosporium, cotton dust and house dust, which had elicited 4 + reactions and the desensitization was started with 1: 50,00,000(×),1:5,00,000(A) and 1:50,000(B) biweekly with incremental doses. The source of the therapeutic allergens was Patel Chest Institute and Centre for Biochemical Technology (CBT). Desensitization was commenced from Dec 1990 with biweekly shots which went on till 1:50 and later on maintenance was carried out till May 1991 with 1:500 at weekly and fortnightly shots.
Symptoms reappeared in year 2000 and due to peer and family pressure, he shifted to homeopathy but soon discontinued it since he had to be admitted to a nursing home for 3 days with increasing breathlessness and an unconfirmed diagnosis of pneumonia. He then continued Inhaled corticosteroid plus long acting beta agonist.
Patient relocated to Abu Dhabi (UAE) for work purpose and between 2007 and 2013 he worked for a chemical company and became symptomatic only during sand storms and change in season for which he took his company doctors oral treatment for up to 7 days, followed by ipratropium inhalations sos as prescribed by the company physician. His medical file contained a complete blood count report dated May 1998 which showed hemoglobin of 16.2, total leukocyte count of 10,300, and eosinophil differential count of 10%. He rated his health status as alright during his Gulf stay.
On 20 December 2012 after a gap of 21 years at the age of 43, he reported back due to increased symptoms of congestion and chest tightness. [4] His father had expired due to increasing breathlessness and cardiac arrest. On seeking more details about his father, he said that his father was 65 of age at the time of death and 3 weeks prior to his death he was diagnosed to have advanced pulmonary tuberculosis. He disclosed that his father had been smoking 20 cigarettes since the age of 15 years and was always reluctant to seek medical advice. He also reported that his brother was suffering from acute lymphocytic leukemia since 9 years and he raised concerns about him suffering from malignancy or fatal asthma. He also felt that allergen immunotherapy had protected him in spite of working in a chemical company, where he was exposed to fumes and gases.
His ECG was normal. His PEFR was 470 postbronchodilator. SpO2 was 97%, heart rate of 88, and blood pressure of 130/80. His height was 173 cm and weight was 82 kg with a body mass Index of 27.42. There were few sibilant ronchi although his spriometric parameters postbronchodilator were supranormal as follows: FVC 4.44 (119%), FEV1 3.59 (128%), FEV1/FVC 100%, FEF25-75 3.24 (114%), and PEFR 506 (110%) done on Schiller SP1 model calibrated on 26-7-12. His laboratory values were as follows: Hemoglobin 14.9 g%, total leukocyte count 8600 cumm, neutrophils 68%, eosinophils 4%, lymphocytes 26%, monocytes 2%, and erythrocyte sedimentation rate 22. [5] His total IgE was 18.24. Fasting blood sugar 99, bilirubin − normal, human immunodeficiency virus I and II was nonreactive. His chest X ray and paranasal X ray − waters were normal. He was considered to be having nonatopic reversible airway obstructive disease. He was continued on Ipratropium inhalations since he was doing fine on it and given a course of monteleukast 10 mg for 20 days. He was given influenza vaccine on 25 th December 2012 and pneumococcal vaccine on 31 December 2012. He was advised repeat allergy testing and desensitization with newer and more allergens.
In July 2013, while on salbutamol plus ipratropium meter dose inhaler, 1+1 puff morning and 1 + 1 puff evening alone and off oral drugs for 10 days, he was subjected to intradermal allergy tests with 120 pollens, fungi, dusts, danders, and food. The reaction sizes were as follows Acacia (19mm), Adathoda (16 mm), Rumex (16 mm), Amaranthus, Ageratum, and Phoenix (all 14 mm). Reactions to holoptelia was 12 mm and lawsonia was 11 mm.(Positive control − 22 mm, negative control − 09 mm). Direct measurements of skin reaction size were done instead of test gradations as + 1 to + 4.
Fungi, danders, and insects results were A. tamari − 11mm, Cladosporium − 13 mm, cotton dust − 13 mm, and house dust − 12 mm, all insignificant, demonstrating that the hyposensitizations had been effective through 23 years or had spontaneous remission as specific IgE was not done [Table 1]. [6],[7],[8]  | Table 1: Allergens tested with skin Reactions in 1985 and 2013 with significance(S) and NS(Nonsignificance) in bold indicating successful desensitization
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His reactions to A. fumigatus was 16 mm, ration shop dust 18 mm, ants 20 mm, cockroach male 23 mm, cockroach female 19 mm, housefly 25 mm, mosquito 18 mm, and house dust mite 18 mm (butterfly and moth were not included). He seemed to be more sensitized now to A. fumigatus as compared with A. tamari, showing success of desensitization or spontaneous remission. Although he had remained sensitive to ants, he had developed new reactions to other insect allergens including house dust mite (HDM) [Table 1]. Some of the allergens also elicited late positive reactions after 48 h.
Significant skin test results to 40 food items testing were, beef-17 mm, cashew-14 mm, chicken-16 mm, mutton-15 mm, sonf-13 mm, pea-18 mm, prawn-21 mm, and rice-17 (positive control − 16 mm and negative control − 10 mm) [Table 1]. He had developed new food allergies in addition to milk especially nonvegeterian items which he claimed to consume in plenty in the middle east. He was advised to restrict abovementioned food items items for one month and as and when symptoms increased.
| Observations | | |
- Stepwise pharmacotherapy protects growing children from stunting and induces very small increments in body mass index probably due to better control resulting in more physical activities
- Systematic-specific allergen desensitization for 6 months had a suppressive effects due to blocking antibodies and/or other proven mechanisms for more than 10 years
- Newer allergies developed after a significant lapse of time
- Aeroallergens from V.P chest Institute were effective as early as 1990s in retrospect
- Late positive reactions can develop in patients with normal total immunoglobulin E levels
- Patients preference to therapy changed as per availability, access, needs, and events prompting him to make free independent choices
- Skin test results change over time.
| Conclusions | | |
- Stepwise treatment of asthma induces remissions that may itself be long-lasting.
- Allergen immunotherapy may compliment pharmacotherapy to induce longer remissions
- Spontaneous remissions are known to occur in asthma. Allergy testing may help to determine if it is spontaneous or due to intervention of immunotherapy.
- It is likely that his current attacks were induced by pollens showing immediate hypersensitivity and sustained due to those with late positive reactions.
- Allergy and asthma show secular and dynamic trends in the nature of triggers and managements as well.
- Optimum pharmacotherapy combined with allergen immunotherapy tends to normalize spirometric curves.
| References | | |
| 1. | Immediate hypersensitivity: Approach to diagnosis. Ch. 2, Andrew Saxon in Manual of Allergy and immunology. Little Brown; 1988. p. 15-35. 
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| 2. | Shivpuri DN, Agarwal MK. Studies on allergenic fungal spores of Delhi, India, metropolitan area. Clinical aspects. J Allergy 1969;44:204-12.
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| 3. | King GG. The effect of body weight on airway caliber. Eur Respir J 2005;25:896-901.
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| 4. | Sharma DK. Role Of Immunotherapy in Nasobronchial Allergies. Indian J allergy Asthma Immunol 2003;17:25-8.
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| 5. | Mishra JK. An immunological study of Bronchial Asthma with special reference to IL4, IF alpha and Immunoglobulin E Indian Journal of All. Asthma Immunol 2011;25:91-6.
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| 6. | Gaur SN. Progress and prospects of Allergen Immunotherapy in next millennium. Indian J Allergy Asthma Immunol 2002;16:83-8.
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| 7. | Gaur SN, Editorial. Ind J Allergy Appl Immunol 1997;11:i-ii.
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| 8. | Gaur SN and Gupta S. Clinical response to immunotherapy in cases of nasobronchial allergy. Ind J Allergy Appl Immunol 1996;10:65-8.
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[Figure 1]
[Table 1]
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