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The corresponding postcontrast T1-weighted image (D) shows the enhancing mass (black arrows) buy discount prazosin 2 mg online cholesterol in eggs yolk or white. The normal order prazosin once a day cholesterol medication equivalents, avidly enhancing mucosa in the right nasal cavity ( open white arrow) can easily be distinguished from the less intensely enhancing tumor generic prazosin 2mg mastercard high cholesterol foods avoid list. The bony boundary between the mass and the intracranial contents is breached ( small white arrows) purchase prazosin online pills cholesterol medication day or night. Imaging examinations are designed not only to recognize acute disease processes, but also to identify any anatomic variations that may be causative factors. Furthermore, imaging helps map out a course of action for the surgeons and helps to identify potential areas at risk for complications. Although sinusitis is essentially a clinical diagnosis, there are some imaging correlates. In addition, the complications from the natural progression of the primary disease process or from surgery are best diagnosed by imaging studies. The exact relationship of allergy to the various inflammatory disease processes affecting the sinus remains unclear. Inflammatory disease processes can have a nearly identical appearance to the more aggressive fungal and malignant entities; therefore, close attention to the imaging findings is required in order to differentiate these processes. A contemporary look at the imaging issues of sinusitis: sinonasal anatomy, physiology and computed tomography technique. The osteomeatal unit and endoscopic surgery: anatomy, variations, and imaging findings in inflammatory diseases. Relationship between patient based descriptions of sinusitis and paranasal sinus computed tomographic findings. Chronically obstructed sinonasal secretions: observations on T1 and T2 shortening. Endoscopic paranasal sinus surgery: radiographic evaluation of severe complications. Role of nasal allergy in chronic maxillary sinusitis diagnostic value of nasal challenge with allergen. Immunologic diseases of the lungs can manifest radiographically as diffuse or focal pulmonary parenchymal and airway disease ( 1,2). Although chest radiographs are usually abnormal in advanced disease, characterization is frequently impossible. It is a technique in which continuous rotation of the x-ray tube and data acquisition are coupled with continuous movement of the patient through the gantry. The width of the x-ray beam is called collimation and determines this section thickness. By using a very thin section, structural superimposition within the section of thickness is reduced, permitting optimal evaluation of lung detail. Contrast can help to distinguish lymph nodes from pulmonary vessels, characterize pleural disease, demonstrate vascular components of an arterial venous malformation, and detect pulmonary emboli. Intravenous contrast should be avoided in patients with a creatinine level above 2. Low osmotic contrast is now preferred because it has fewer side effects and should be used in patients with previous anaphylactoid reactions to radiocontrast media. Corticosteroid pretreatment supplemented with antihistamine, diminishes the risk of adverse reactions. Each level contains an airway and a pulmonary artery that act as a supporting structure, the peribronchovascular interstitium. The secondary pulmonary lobule is the smallest unit of lung structure marginated by connective tissue septa ( 8). In idiopathic pulmonary fibrosis and fibrosing alveolitis associated with collagen vascular disease, this pattern is most often observed peripherally at the lung bases (3,5). In chronic hypersensitivity pneumonitis the fibrosis is usually most severe in the mid-lung zones ( 9,10). Cysts or rounded air-containing nodules are present in a number of acute and chronic infiltrative diseases. High-resolution computed tomography demonstrates disruption of the underlying lung architecture, with a honeycomb pattern of thick irregular basilar septal lines ( arrowhead) surrounding small cystic air spaces. Ground-glass attenuation is characterized by the presence of hazy increased attenuation of lung without obscuration of the underlying bronchial or vascular anatomy. Ground-glass attenuation can result from interstitial thickening, air space filling, or both. Although ground-glass attenuation is nonspecific, it usually indicates the presence of an active, potentially treatable disease. Areas of ground-glass attenuation in patients with chronic infiltrative lung disease are commonly caused by hypersensitivity pneumonitis, collagen vascular diseases, and idiopathic pulmonary fibrosis ( 3,5). The syndrome is most commonly seen in patients 30 to 50 years of age and has no gender predilection. Patients are typically asthmatic and present with eosinophilia, fever, and allergic rhinitis. Findings of chest radiography are usually abnormal and most often consist of patchy nonsegmental areas of consolidation with no zonal predominance. The areas of consolidation may have peripheral distribution and are often transient ( Fig. Computed tomography demonstrates irregular areas of consolidation ( arrows) in this 57-year-old woman with previous episodes of eosinophilic pneumonia. Nodules, bronchial wall thickening, and bronchiectasis are common with both Churg-Strauss syndrome and allergic bronchopulmonary aspergillosis. Other less common findings include pulmonary nodules, interlobular septal thickening, and bronchial wall thickening ( 12). Bronchocentric Granulomatosis Bronchocentric granulomatosis involves the bronchi and bronchioles. This entity can be classified into those patients with asthma and those without ( 13,14). Pathologically it is characterized by thick-walled ectatic bronchi and bronchioles containing viscous material. Wegener Granulomatosis Wegener granulomatosis is a systemic autoimmune disease characterized by a granulomatous vasculitis of the upper and lower respiratory tracts. The histologic features are a necrotizing vasculitis of small arteries and veins and granuloma formation. The clinical triad of classical Wegener granulomatosis is pulmonary disease, febrile sinusitis, and glomerulonephritis ( 2,15). The imaging findings in most patients are multiple nodules or irregularly marginated masses with no zonal predominance. The nodules or masses are usually multiple but can be solitary in approximately 25% of cases. After treatment, the nodules or cavities may resolve completely or result in a scar. Peripheral, wedge-shaped areas of consolidation representing an infarct may be present.

For example generic 2 mg prazosin free shipping cholesterol levels yogurt, these numbers suggest that it should be easier to achieve herd immunity for poliomyelitis and smallpox than for measles prazosin 1mg online cholesterol medication examples, mumps purchase prazosin 1 mg without prescription cholesterol levels high during pregnancy, and rubella buy discount prazosin 1mg on-line acceptable cholesterol per day. This conclusion is justied by the actual eectiveness of vaccina- tion programs in reducing, locally eliminating, and eradicating these diseases (eradi- cation means elimination throughout the world). The information in the next section veries that smallpox has been eradicated worldwide and polio should be eradicated worldwide within a few years, while the diseases of rubella and measles still persist at low levels in the United States and at higher levels in many other countries. For centuries the process of variolation with material from smallpox pustules was used in Africa, China, and India before arriving in Europe and the Americas in the 18th century. Edward Jenner, an English country doctor, observed over 25 years that milkmaids who had been infected with cowpox did not get smallpox. In 1796 he started vaccinating people with cowpox to protect them against smallpox [168]. Two years later, the ndings of the rst vaccine trials were published, and by the early 1800s, the smallpox vaccine was widely available. Smallpox vaccination was used in many countries in the 19th century, but smallpox remained endemic. Smallpox was slowly eliminated from many countries, with the last case in the Americas in 1971. The last case worldwide was in Somalia in 1977, so smallpox has been eradicated throughout the world [23, 77, 168]. Most cases of poliomyelitis are asymptomatic, but a small fraction of cases result in paralysis. In the 1950s in the United States, there were about 60,000 paralytic polio cases per year. In 1955 Jonas Salk developed an injectable polio vaccine from an inactivated polio virus. This vaccine provides protection for the person, but the person can still harbor live viruses in their intestines and can pass them to others. In 1961 Albert Sabin developed an oral polio vaccine from weakened strains of the polio virus. This vaccine provokes a powerful immune response, so the person cannot harbor the wild-type polio viruses, but a very small fraction (about one in 2 million) of those receiving the oral vaccine develop paralytic polio [23, 168]. The Salk vaccine interrupted polio transmission and the Sabin vaccine eliminated polio epidemics in the United States, so there have been no indigenous cases of naturally occurring polio since 1979. In order to eliminate the few cases of vaccine-related paralytic polio each year, the United States now recommends the Salk injectable vaccine for the rst four polio vaccinations, even though it is more expensive [50]. In the Americas, the last case of paralytic polio caused by the wild virus was in Peru in 1991. Most countries are using the live-attenuated Sabin vaccine, because it is inexpensive (8 cents per dose) and can be easily administered into a mouth by an untrained volunteer. Measles is a serious disease of childhood that can lead to complications and death. For example, measles caused about 7,500 deaths in the United States in 1920 and still causes about 1 million deaths worldwide each year [47, 48]. Measles vaccinations are given to children between 6 and 18 months of age, but the optimal age of vaccination for measles seems to vary geographically [99]. But the replacement number R remained above 1, so that smallpox per- sisted in most areas until the mid-20th century. In 1966 smallpox was still endemic in South America, Africa, India, and Indonesia. Because the goal of a rubella vaccination program is to prevent rubella infections in pregnant women, special vaccination strategies such as vaccination of 12 to 14-year-old girls are sometimes used [98, 101]. This 1976 photograph shows schoolchildren in Highland Park, Illinois, lining up for measles vaccinations. Because of a major outbreak in 1989 1991, the United States changed to a two-dose measles vaccination program. The replacement number R now appears to be below 1 throughout the United States, so that measles is no longer considered to be an indigenous disease there. Thus to reach the levels necessary to achieve herd immunity, the vaccinated fractions would have to be at least 0. These fractions suggest that achieving herd immunity would be much harder for measles than for rubella, because the percentages not vaccinated would have to be below 1% for measles and below 9% for rubella. Because vaccinating all but 1% against measles would be dicult to achieve, a two-dose program for measles is an attractive alternative in some countries [50, 98, 99]. In the prevaccine era, every child had measles, so the incidences were approximately equal to the sizes of the birth cohorts. After the measles vaccine was licensed in 1963 in the United States, the reported measles incidence dropped in a few years to around 50,000 cases per year. In 1978 the United States adopted a goal of eliminating measles, and vaccination coverage increased, so that there were fewer than 5,000 reported cases per year between 1981 and 1988. Pediatric epidemiologists at meetings at the Centers for Disease Control in Atlanta in November 1985 and February 1988 decided to continue the one-dose program for measles vaccinations instead of changing to a more expensive two-dose program. Each year some of the reported cases are imported cases and these imported cases can trigger small outbreaks. The proportion of cases not associated with importation has declined from 85% in 1995, 72% in 1996, 41% in 1997, to 29% in 1998. Analysis of the epidemiologic data for 1998 suggests that measles is no longer an indigenous disease in the United States [47]. Measles vaccination coverage in 19 to 35-month-old children was only 92% in 1998, but over 99% of children had at least one dose of measles-containing vaccine by age 6 years. Because measles is so easily transmitted and the worldwide measles vaccination coverage was only 72% in 1998 [48, 168], this author does not believe that it is feasible to eradicate measles worldwide using the currently available measles vaccines. In recent rubella outbreaks in the United States, most cases occurred among unvaccinated persons aged at least 20 years and among persons who were foreign born, primarily Hispanics (63% of re- ported cases in 1997) [46]. Worldwide eradication of rubella is not feasible, because over two-thirds of the population in the world is not yet routinely vaccinated for rubella. Indeed, the policies in China and India of not vaccinating against rubella may be the best policies for those countries, because most women of childbearing age in these countries already have disease-acquired im- munity. Chickenpox is usually a mild disease in children that lasts about four to seven days with a body rash of several hundred lesions. Shingles is a painful vesicular rash along one or more sensory root nerves that usually occurs when the immune system is less eective due to illness or aging [23]. But the vaccine-immunity wanes, so that vaccinated children can get chickenpox as adults. Two possible dangers of this new varicella vaccination program are more chickenpox cases in adults, when the complication rates are higher, and an increase in cases of shingles. An age-structured epidemiologic-demographic model has been used with parameters estimated from epidemiological data to evaluate the eects of varicella vaccination programs [179]. Although the age distribution of varicella cases does shift in the computer simulations, this shift does not seem to be a problem since many of the adult cases occur after vaccine-induced immunity wanes, so they are mild varicella cases with fewer complications.

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Specific antibody titers should be measured against polysaccharide as well as protein antigens ( 51 purchase prazosin 1 mg overnight delivery cholesterol levels very low,52) prazosin 2mg low price cholesterol medication best time to take. Although measurement of isohemagglutinins may be used to screen for the ability to produce antibodies against polysaccharides (the A purchase prazosin 2mg with mastercard cholesterol medication side effects australia, B purchase prazosin american express cholesterol free eggs calories, or both blood group substances in patients of other blood groups), the availability of measurement of antibodies against specific bacterial antigens (see later) has decreased dependence on those assays. We usually request measurement of antibodies against tetanus and diphtheria toxins and several pneumococcal polysaccharides as well as H. Testing for these and additional antibody titers are available in many commercial laboratories and are sometimes referred to as a humoral immunity panel. An advantage of using these particular antigens is that they are contained in readily available, well-tested vaccines, which often have already been given to or will be clinically indicated for the patients in question, so that exposure to the antigen is definite. Obtaining titers before, as well as 4 to 8 weeks after, immunization allows comparison of the response to each antigen. The absence of a threefold rise in titer after immunization or failure to achieve protective levels indicates that the patient is unable to mount specific antibody responses. This may be seen either with protein or polysaccharide antigens and may indicate a failure to process properly or recognize an entire class of antigens, such as in what has been termed specific polysaccharide antibody deficiency, or certain particular antigens in what may be considered a lacunar defect. In some rare cases, patients already receiving immunoglobulin infusions may require assessment of their own specific antibody production, which may be difficult because antibodies against many common antigens will have been acquired passively. In most cases, the immunoglobulin therapy can be stopped for a few months so that the patients can be immunized and their own antibody production measured while they are being reassessed clinically. If this is not possible, special test antigens, such as keyhole limpet hemocyanin and the bacteriophage fX174, can be obtained from specialized centers ( 53). Because most individuals and plasma donors have not been commonly exposed to these antigens, commercial immunoglobulin preparations do not contain antibodies against them, and they can be used to assess de novo specific antibody formation. Lectins, proteins generally derived from plants that bind specific polysaccharides, commonly present in surface glycoproteins on human cells and are frequently used as the stimuli in such assays. Because these proteins stimulate most human lymphocytes, regardless of prior antigen sensitization, they are called mitogens, and tests using them should be referred to as lymphocyte mitogen proliferation assays. Plant lectins often used as stimuli for mitogen proliferation assays include concanavalin A, phytohemagglutinin, and pokeweed mitogen. Mitogen stimulation tests are useful even in newborns who have not received any immunizations and may be particularly informative about lymphocyte function and immune competence in babies with partial T-cell deficiency, such as those with DiGeorge syndrome (55). Disadvantages of these tests include the requirements for several milliliters of blood, which may be prohibitive for small newborns; time constraints that may be imposed by the laboratory to facilitate isolation of the mononuclear cells during normal working hours; and the fact that the cells must be cultured for 3 several days (usually 48 to 72 hours) before they are pulsed with H-thymidine to assess its incorporation. Staphylococcal enterotoxins are also often employed as stimuli in proliferation assays because they function as superantigens, which stimulate broad families of T cells by binding to parts of their T-cell receptors other than the antigen-binding site. The response to these superantigens is thus also independent of prior antigen sensitization. The Cowen strain of Staphylococcus aureus may be used as a T-cell independent stimulus for B-cell proliferation. T-cell proliferative responses to recall antigens may also be assessed using similar techniques, although because a smaller number of T cells will respond to any given antigen than to the more broadly reacting 3 mitogens discussed previously, these tests commonly involve 4- to 5-day incubation periods before the H-thymidine is added and its incorporation determined. Obviously, antigen responses can only be expected if it is documented that the patient has been exposed to the antigen in question. However, if an older child is known to have received his or her scheduled immunizations, or if candidal infection has been obvious, the response to soluble candidal preparations and vaccine antigens such as tetanus toxoid may be useful. Detailed laboratory analysis in patients suspected of phagocyte disorders should include assessment of neutrophil chemotaxis and the oxidative respiratory burst that accompanies phagocytosis (37,57,58). Chemotaxis is assessed by measuring the migration of polymorphonuclear leukocytes through agar gels or across filters in specially designed Plexiglas (Boyden) chambers. The oxidative burst can be assessed by the nitroblue tetrazolium test, in which a soluble yellow dye is reduced to an easily visible insoluble blue intracellular precipitate ( 59). Flow cytometric assays in which oxidized products are detected by fluorescence may also be employed (58). These laboratories can also screen for abnormalities of the alternative pathway, which may be indicated in patients who have recurrent bacterial infections or bacteremia and sepsis but in whom antibodies and the classic pathway have been found to be normal. However, an additional level of definition is now possible in many hospital laboratories and may aid the practitioner in providing prognostic and genetic counseling information for patients and their families. Furthermore, the practitioner should recognize the importance of defining the molecular defects in the management of immune-deficient patients because several forms of specific therapy are already available and new modalities are being developed at a rapid rate as a result in advances in understanding of the physiology of lymphocytes and cytokines as well as the genome project. Importantly, within the B-cell disorders, the pattern of X-chromosome inactivation ( 60) can be used to determine whether female family members are carriers of Bruton agammaglobulinemia (61). The most likely defect can then be confirmed in specialized research laboratories using assays for the specific protein (Western blot or flow cytometry) or gene that is suspect. Fluorescence in situ hybridization can be used to confirm the chromosome abnormality in patients suspected of having DiGeorge or velocardiofacial syndrome, overlapping sets of anomalies that may be associated with partial T-cell deficiencies and are due to microdeletions in chromosome 22q11. If there is no potential donor who matches at all loci, transplantation of T-cell depleted marrow from a donor with a mismatch at one or more loci might be considered but is performed only at certain research centers. Anticoagulated whole blood should be sent to a research center with expertise in these assays ( 66) in cases of T-cell deficiency with impaired mitogen responses. For these reasons, special precautions must be initiated as soon as this type of immune defect is suspected, while the immunologic workup is proceeding and plans for referral and definitive treatment are being formulated. With current recommendations in the United States abandoning the use of the live attenuated oral polio vaccine and replacing it with inactivated vaccine only, polio is less of a risk. However, immunization with Bacille-Calmette-Gurin vaccine is practiced in many other countries and may lead to fatal infection. Trimethoprim-sulfamethoxazole or other appropriate regimens should be should be used for prophylaxis against P. This may need to be continued for more than a year, even in children who have received bone marrow transplants, because functional B-cell engraftment is often delayed. Although patients with X-linked agammaglobulinemia, X-linked hyper-IgM syndrome, and other severe immunoglobulin deficiencies generally clearly require immunoglobulin replacement (see later), others with less severe deficiencies often require complex judgment processes. In deciding which form of therapy may be most appropriate for any given patient, the practitioner must consider not only the underlying diagnosis but also the exposure history, the cumulative morbidity and future risk for end-organ damage from infection, and the risks and adverse effects of the various therapeutic options. Often, antibody-deficient patients who present with repeated acute infections also have systemic morbidity, about which they may or may not complain. This may include fatigue, lack of stamina, poor weight gain (in infants), and musculoskeletal symptoms that have been attributed to other causes or ignored. Because these symptoms often improve with appropriate management of chronic infection and immunoglobulin replacement, they must be carefully evaluated in the review of systems and weighed in considering the options for therapy. Patients with a history of inflammatory bowel disease, recurrent problems with Clostridium difficile, or drug allergies may have decreased tolerance for antibiotics, which may limit the therapeutic options in their cases. A stepwise approach to treatment may be employed across the range of severities of antibody deficiency or sequentially in any given patient. Some patients, particularly small children, with partial antibody deficiency who have not had significant permanent end-organ damage may be managed by limiting their exposure to infectious agents (e.

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The occurrence of venom anaphylaxis after first known insect sting exposure is another confusing observation buy generic prazosin from india low cholesterol yogurt, raising the issue of the etiology of prior sensitization or the pathogenesis of this initial reaction prazosin 1mg low cost cholesterol ratio tool. People who have had large local reactions usually have positive venom skin tests and often very high titers of serum venom-specific immunoglobulin E (IgE); thus purchase prazosin no prescription fasting cholesterol test tea, these tests do not discriminate the few potential anaphylactic reactors generic prazosin 1mg mastercard cholesterol medication drugs. Anecdotal observations suggest that the use of b-blocking medication, which certainly potentiates the seriousness of any anaphylactic reaction, may also be a risk factor for subsequent occurrence of anaphylaxis in people who have had large local reactions. Many simultaneous stings (greater than 100) may sensitize a person, who then might be at risk for anaphylaxis from a subsequent single sting. This potential problem is now recognized more often because of the many stings inflicted by the so-called killer bees. After experiencing a large number of stings with or without a toxic clinical reaction, people should be tested to determine the possibility of potential venom allergy. After an uneventful insect sting, some people may develop a positive skin test, which is usually transient in occurrence. A report from Johns Hopkins suggested that if the skin test remains positive for a long period of time, 5 to 10 years, 17% of people have a systemic reaction after a subsequent sting ( 16). If these data were verified, it would raise the question of venom skin tests for individuals who have tolerated insect stings. If the test remains positive, people might be advised to have medication available for treatment of an allergic reaction. Currently, skin testing of people who have no allergic reaction from a single sting is not recommended. The natural history of insect sting anaphylaxis has now been well studied and is most intriguing. People who have had insect sting anaphylaxis have an approximate 60% recurrence rate of anaphylaxis after subsequent stings ( 17). Viewed from a different perspective, not all people presumed to be at risk react to re-stings. The incidence of these re-sting reactions is influenced by age and severity of the symptoms of the initial reaction. For example, children who have had dermal symptoms (hives, angioedema) as the only manifestation of anaphylaxis have a remarkably low re-sting reaction rate ( 17,18). On the other hand, individuals of any age who have had severe anaphylaxis have an approximate 70% likelihood of repeat reactions ( 17,19). When anaphylaxis does reoccur, the severity of the reaction tends to be similar to the initial reaction. No relationship has been found between the occurrence and degree of anaphylaxis and the intensity of venom skin test reactions. On occasion, these reactions have also been associated with an immediate anaphylactic reaction. People who have this serum sickness type reaction are subsequently at risk for acute anaphylaxis after repeat stings and thus are considered candidates for venom immunotherapy ( 20). Toxic Reactions Toxic reactions may occur as a result of many simultaneous stings. The differentiation between allergic and toxic reactions sometimes can be difficult. As noted, after a toxic reaction, individuals may develop IgE antibody and then be at risk for subsequent allergic sting reactions following a single sting. Beekeepers have high levels of serum venom-specific IgG, correlating to some extent with the amount of venom exposure (stings). These IgG antibodies are capable of blocking in vitro venom-induced histamine release from basophils of allergic individuals. In addition, administration of hyperimmune gammaglobulin obtained from beekeepers provided temporary immunity from venom anaphylaxis in sensitive individuals ( 24). Successful venom immunotherapy is accompanied by the production of high titers of venom-specific IgG. These observations suggest that IgG antibodies reacting with venom have a protective function. The vespid venoms (yellow jacket, hornet, and wasp) are obtained by dissecting and crushing the individual venom sacs. People with relevant stinging insect histories should undergo skin tests with the appropriate dilutions of each of the available five single Hymenoptera venom preparations. Venom dilutions must be made with a special diluent that contains human serum albumin. The initial studies of venom skin tests concluded that an immunologically specific reaction suggesting that the patient is sensitive is a reaction of 1+ or greater at a concentration of 1 g/mL or less, provided the 1+ reaction is greater than that of a diluent control ( 25). Reactions to only 1 g/mL must be evaluated carefully because another study of skin test reactions in an insect nonallergic population showed that 46% of individuals reacted to this concentration of at least one venom ( 26). Venom concentrations higher then 1 g/mL cause nonspecific or irritative reactions and do not distinguish the insect-nonallergic from the insect-allergic population. Currently, there is no explanation to resolve this apparent discrepancy in the sensitivity of the in vivo and in vitro tests. This issue has practical significance because many allergists, including myself, believe that a negative skin test reaction indicates lack of or loss of clinical venom allergy. Histamine release from leukocytes is basically a laboratory procedure too cumbersome for routine diagnostic evaluation. Recommendations for therapy include measures to minimize exposure to insects, availability of emergency medication for medical treatment of anaphylaxis, and specific venom immunotherapy. Avoidance The risk for insect stings may be minimized by the use of simple precautions. Individuals at risk should protect themselves with shoes and long pants or slacks when in grass or fields and should wear gloves when gardening. Black and dark colors also attract insects; individuals should choose white or light-colored clothes. Food and odors attract insects; thus, garbage should be well wrapped and covered, and care should be taken with outdoor cooking and eating. Medical Therapy Acute allergic reactions from the insect stings are treated in the same manner as anaphylaxis from any cause. Patients at risk are taught to self-administer epinephrine and are advised to keep epinephrine and antihistamine preparations available. Consideration should be given to having an identification bracelet describing their insect allergy. Venom Immunotherapy Venom immunotherapy has been shown to be highly effective in preventing subsequent sting reactions ( 31,32). Successful therapy is associated with the production of venom-specific IgG, which appears to be the immunologic corollary to clinical immunity. Current recommendations are to administer venom immunotherapy to individuals who have had sting anaphylaxis and have positive venom skin tests. As discussed previously, recent studies of the natural history of the disease process in untreated patients have led to observations that modify this recommendation. The presence of IgE antibody in an individual who has had a previous systemic reaction does not necessarily imply that a subsequent reaction will occur on reexposure. Observations relevant to the decision to use venom immunotherapy include age, interval since the sting reaction, and the nature of the anaphylactic symptoms.

Chironomid larvae are used as fish food buy prazosin online cholesterol definition nutrition, resulting in symptoms among workers in their production order prazosin 2mg fast delivery zetia cholesterol medication side effects, laboratory personnel purchase prazosin 1 mg mastercard cholesterol risk ratio formula, and hobbyists ( 231) cheapest prazosin how many cholesterol in eggs. Asthma and rhinitis occur in some bee keepers and in workers involved in honey production because of inhalation of honeybee body components. Occupational allergy has been reported in laboratory workers dealing with locusts ( 236). In these workers, as in the case of murine allergen-sensitive laboratory workers, atopy was not a prerequisite for sensitization. The primary locust allergen is the peritrophic membrane that surrounds food particles when they pass through the midgut and eventually become feces. The common housefly (Musca domestica) also has been reported as a cause of occupational allergy in laboratory workers ( 237), as has the grain beetle (Alphitobius diaperinus). Larval, pupal, and adult stages of the life cycle of this beetle all are capable of inducing allergy, but pupal extract contains the most significant allergens (238). Other case reports have described generalized reactions to multiple bites (deer fly) consisting of fever, malaise, and hypotension associated with antibodies to the offending insect. Experimental sensitization in humans with flea bites results first in the induction of delayed, and then in immediate, wheal-and-flare hypersensitivity on skin testing. Hypersensitivity to the venom of stinging insects (Hymenoptera) is the subject of another chapter and is not discussed here. Cottonseed and flaxseed are exceptionally potent antigens and should be used for skin testing only by the epicutaneous method. After extracting the oil, which is not allergenic, the seed is ground into meal, which may be used for animal feeds or fertilizer. Cottonseed meal and flour also are used in the baking industry for certain cakes, cookies, and pan-greasing compounds. Cotton linters are the short cotton fibers that adhere to the seeds after the cotton is ginned. Enough of the water-soluble cottonseed allergen adheres to these linters to render them allergenic ( 239). Several cases of angioedema, urticaria, or anaphylaxis have been reported in individuals who have eaten whole-grain bread or candy containing cottonseed meal ( 240,241). Flaxseed (linseed) has the same properties as cottonseed and has many of the same general uses in industry and agriculture. Additional uses are in hair preparations, poultices, electric wire insulation, and the tough backing material used in the manufacture of rugs. Coffee bean allergy is largely confined to those who handle the green beans commercially, including longshoremen who unload the sacks of beans from ships. Chlorogenic acid has been considered an allergen in green coffee beans, castor beans, and oranges. Its importance is questionable, however, because it is destroyed by roasting and thus cannot account for allergy from drinking coffee. Castor bean ( Ricinus communis) allergy is mainly from the pulp and hull that remain after castor oil is pressed from the bean. Low-molecular-weight protein fractions have been isolated, as well as a toxic substance, ricin, which is not allergenic. Castor bean allergy also may occur in neighborhoods adjacent to processing plants. Asthma and rhinitis have been reported from the protein residual in the ambient air. A study from Marseilles, France, reports the incidence of castor bean allergy to be the same in atopic and nonatopic individuals ( 242). Three allergenic castor bean proteins have been identified by protein electrophoresis. The 2S albumins represent one of two common storage proteins found in a variety of seeds, including sunflower seeds, Brazil nuts, and rapeseeds. Like other sensitizing allergenic proteins, these have low molecular weights, are highly soluble in water, and generally have no toxicity for nonallergic persons ( 245). Soybean allergy may be more generalized and prevalent because of the increased use of soy flour and meal in commonly encountered products. Occupational asthma caused by soybean flour used as a protein expander in frozen meat patties has been reported. Asthma epidemics have occurred in Barcelona, Spain, in association with unloading soybeans from ships. Case studies of those affected show a high incidence of IgE antibodies to soybean allergens. Subsequent investigations have shown that the major allergens are glycoproteins found in the hulls and dust, with molecular sizes less than 14 kDa (247,248 and 249). Impure gelatin is the adhesive obtained from the bones and hides of terrestrial animals and fish bones. Synthetic adhesives recently have minimized the glue allergy problem, although the amine hardeners used in the manufacture of epoxies have caused asthma and rhinitis in factory workers. Guar gum is a vegetable gum that recently has been shown to induce IgE-mediated asthma. This gum is used in the carpet industry and affects about 2% of workers in carpet-manufacturing plants. It is also used in ice cream and salad dressings and as a hardener in the manufacture of tablets in the pharmaceutical industry. Guar gum is obtained from Cyanopsis tetragonoolobus, a vegetable grown in India (250). In hair-setting preparations, gums have been largely replaced by polyvinylpyrrolidine, which is not allergenic. Parenthetically, most cases of chronic pulmonary disease attributed to hair spray allergy or hair spray thesaurosis have turned out to be sarcoidosis, with no basis for attributing the cause to hair spray. This wood dust is a product of the Quillaja tree and is used in the manufacture of saponin, a surface-reducing agent. Enzymes used in laundry detergents to enhance cleaning ability may sensitize both the workers where the product is made and the consumer who uses it ( 252). The enzyme subtilisin (or subtilin) is proteolytic and is derived from Bacillus subtilis, where it plays a role in sporulation. It may produce rhinitis, conjunctivitis, and asthma, associated with precipitating antibodies and Arthus-type reactions on skin testing. Enzyme-containing detergents currently are not commonly used because of their sensitizing potential. Other enzymes, cellulase and macerozyme, are used to digest cell wall structures of plants. Laboratory workers have been shown to develop IgE-mediated symptoms from inhaling these enzymes ( 253). Asthma has been induced by inhalation of papain, and antipapain IgE and IgG antibodies have been demonstrated in a worker in a meat tenderizer factory. Positive skin test results to extracts of grain mill dust often are seen in patients who have never worked in granaries. Bakers can have IgE reactions to both of these as well as several other Aspergillus niger enzymes (255,256).

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