Allergy in Practice

294 Pages·2006·12.06 MB·English

by  Johannes Ring

JohannesRing · AllergyinPractice
Johannes Ring
Allergy in Practice
With a Foreword by Thomas Platts-Mills
With149Figuresin175Partsand186Tables
Prof.Dr.med.Dr.phil.JohannesRing
KlinikundPoliklinikfürDermatologieundAllergologieamBiederstein
desKlinikumsrechtsderIsarderTechnischenUniversitätMünchen
BiedersteinerStraße29,D-80802München
ISBN3-540-00219-7Springer-VerlagBerlinHeidelbergNewYork
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TitleoftheGermanedition:
JohannesRing,AngewandteAllergologie.3.,neubearbeiteteAuflage
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München2004
ISBN3-89935-128-2
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Preface
µl · 5 ˆ [ * [ ˆ (ancientGreek)
”Avoidoverreactions”(principleofappliedallergology)
Allergyis“in,”andhasbeenforsomeyearsnow.Theterm“allergy”is
nolongeraforeignword.Inspiteofthis,allergiesarestillnotadequate-
ly appreciated either by the general population or by the physicians’
community.Ontheonehand,allergyislikea“fashionabledisease”and
anydisturbanceofwell-beingisregardedasallergy;ontheotherhand,
very severe allergic conditions remain neglected, being left undiag-
nosedanduntreated.Itisdifficulttofindtherightbalancebetweenthe
extremes.
After the first two editions of this book (1982 and 1988) sold over
20,000copies,thepublisherandauthordecidedtocollaborateonanew
andtotallyrewrittenthirdedition.Inthisendeavortheoriginalaimofa
verybriefandprecisebookletcontainingrelevantinformationforaller-
gypracticewasnotforgotten.Thebookstartedasacollectionofshort
informationleafletsforresidentsrotatingthroughtheAllergyDivision
at Munich. It was Dr. J. Aumiller, chief editor of the Munich Medical
Weekly,whothenpersuadedmetowriteaseriesofshortchaptersonal-
lergyinpractice,andIamstillthankfulforthebrutalitywithwhichhe
forcedmerigorouslytoshortenthetext!Inthisthirdedition,whichis
publishedinbothGermanandEnglish,theauthoragainhadafightto
findthemostlogicalmethodofclassification,adifficultyforeverycom-
plexmedicalfield.Therearedifferentpossiblecriteriawhichcanbefol-
lowedforaclassification:
)
Accordingtoorgans(e.g.,allergyofthenose,eye,skin)
)
Accordingtosymptoms(e.g.,urticaria,eczema,asthma)
)
Accordingtopathomechanisms(e.g.,typesaccordingtoCoombs
andGell)
)
Accordingtoallergens(e.g.,foodallergy,animalproteinallergy,
nickelallergy)
)
Accordingtotheclinicalcourseandprognosis(e.g.,acuteorchronic
allergies,life-threateningemergencies)
)
Accordingtogeneticparameters(e.g.,familialallergies,sporadic
allergies)
)
Accordingtoage(e.g.,childhoodallergies,adultallergies)
)
andmanymore
Ifonepushedtheseclassificationstotheirlogicalextent,manyoverlaps
andrepetitionswouldresult.Thelivingorganismisnotnecessarilylogi-
cal,andevenlesssoinitspathophysiologicalvariants.
VI Preface
Nevertheless,weneedtostresstheimportanceofapreciseterminolo-
gyintheindividualchapters;thisisnotasophisticatedphilosophybut
ratherreflectstheinherentproblems,whichmaybeoverlookedatasu-
perficialglance,butwhicharethedailybreadandbutterofseriousaller-
gists.
Furthermore,itwasimportantintheselectionofreferencesnotonly
–asissooftenseennowadays–tolookthrough“threeyearsofMedline”
butalsotoincludeimportantworkfromthepast.Therefore,Ipolitely
askthereader–maybelikeonaholidaytrip–totrustthemoreorlessex-
periencedguidanceoftheauthor;thisguidedtourwillbesubjective,but
Ipromisetorelatethemostimportantpointsinashortandpreciseway.
HereIwanttothankmanypeople.Firstlymyclinicalandexperimen-
talteachersandmentors,Prof.Dr.med.Dr.h.c.mult.OttoBraun-Falco,
themasterofexactclinicaldescription,theunforgettableProf.Dr.med.
WalterBrendel,whogavemethespiritofenthusiasmforimmunology,
Prof.Dr.med.habil.ErichFuchs,thegrandoldmanofGermanallergo-
logyformanydiscussions,fruitfulcriticalremarksandalwaysenlight-
eningexchangesofideasoverthedecades.Prof.Dr.med.AlaindeWeck
hasgivenmemuchscientificinputandhassupportedmeonmywayinto
the international allergy community. Dr. Eng Tan was my teacher as a
“postdoc”attheScrippsClinicandResearchFoundationinLaJolla.To
mypredecessorsatuniversitychairs,Prof.Dr.KarlheinzSchulzandProf.
Dr.TheodorNasemanninHamburg-Eppendorf,Prof.Dr.med.Dr.phil.
SiegfriedBorelliattheDepartmentofDermatology,BiedersteininMu-
nich. I am thankful for the excellent tradition of clinical allergology
whichIwasallowedtocontinue.
I also want to thank my co-workers in allergology, Prof. Dr. med.
BernhardPrzybilla,Priv.-Doz.Dr.med.DieterVielufattheLudigMaxi-
miliansUniversity,andinHamburg,andProf.Dr.JürgenRakoskiand
Priv.-Doz.Dr.UlfDarsowinthedailyworknowattheTechnicalUniver-
sityofMunich.Thefollowingco-workershavehelpedinthepreparation
ofsinglechapters:
Prof.Dr.TorstenSchäfer(epidemiology),Prof.Dr.HeidrunBehrendt
(allergy and environment, allergens), Priv.-Doz. Dr. Thilo Jakob, Dr.
MartinMempel,Prof.Dr.MarkusOllert(pathophysiology,diagnostics,
immunecomplexreactions),Dr.GregorWildiandMr.JanAl(rhinitis,
asthma),Dr.AnkeGauger(urticaria),Dr.KnutBrockow(anaphylaxis),
Dr.VolkerGrimmandMrs.ClaudiaKugler(foodallergy),Priv.-Doz.Dr.
UlfDarsow(eczema),Priv.-Doz.Dr.BernadetteEberlein-König(photo-
allergy,“ecosyndrome”),Dr.StephanieWeissenbacherandDr.Matthias
Möhrenschlager(therapyandprevention),andDr.TheresiaRing(De-
partmentofOphthalmology,LMU,“AllergyandtheEye”).Manythanks
toJohannaGroschandtothenursesoftheDepartmentofDermatology
andAllergyatBiedersteinfortheircontinuousandenthusiasticworkfor
ourpatients!
IwanttothankMrs.MarionPhilippandMrs.GabrieleM.Schröder
(Springer, Heidelberg) for their professional help with the publishing
andprintingandtoDr.ThomasPlatts-MillsfromCharlottesvilleforthe
kindnessofhisforeword!
Finally I want to thank my wife, Prof. Dr. med. Heidrun Behrendt,
Preface VII
headofthe“CentreforAllergyandEnvironment”(“ZAUM–Zentrum
AllergieundUmwelt”),formanifoldsupport,beautifulelectronmicro-
scope pictures and her everlasting contagious critical enthusiasm for
allergyresearch!
Munich,amBiederstein
January2005
Prof.Dr.med.Dr.phil.JohannesRing
Foreword
AllergicdiseasehasbecomeamajoraspectofWesternSociety,bothin
termsofmedicalmanagementandqualityoflife.Howeverunderstand-
ingdiagnosisandmanagementbecomescomplexbecausenotonlyare
theremultipleallergensourcesinvolvedbutalsoalargenumberofdis-
eases.Hayfever,perennialrhinitis,chronicsinusdisease,urticara,atopic
eczema,anaphylaxis,foodallergy,andasthmaeachaffectlargenumbers
ofpatients.Becauseoftheoverallnumbers(15%–20%ofthepopula-
tion)thereareinevitablyalargeproportionofpatientswhoareallergic
orthinktheyareallergicandattributeothersymptomstothismecha-
nism.Oneofthestrikingfeaturesofallergyisthateachdiseasevaries
fromveryserioustotrivialwithnocleardistinction.Thusforeachofthe
majorallergicdiseasestherearemanyindividualswhosesymptomsare
notsufficienttogotoadoctorandalsopatientswhoselivesaremade
miserableandeventhreatenedbythediseases.Understandingthefac-
torswhichcontributetosuchaspectrumofallergicdiseaseisamajor
challenge.
Asthisbookexplainsaccuratediagnosisofsensitizationisessential.
Withoutthis,itisnotpossibletomakearealisticassessmentoftherole
ofallergyinthediseasenortoplantreatment.Foreachdiseasethereare
multiplepotenzialallergensinvolvedandthemanagementstrategiesare
different.Itisnotsurprisingthatassessmentandmanagementofallergic
diseasebecomesconfusingtomanyofthehealthcareprofessionalswho
havetocopewiththisproblem.
ProfessorRingiswellknowninternationallyasanallergistandder-
matologistwhohascontributedtoresearchonallergyforatleast25years
(Heisalsofamousforawonderfulsenseofhumorwhichsadly,butwise-
ly, doesn’t come through in the book). He has now published a book
whichcoversawiderangeofdiseaseswhichareeitherallergicorimmu-
nological and which provides a comprehensive approach to manage-
ment.Inadditionthebookprovidesacompletereferencetocausesfor
eachoftheconditionsassociatedwith“Allergie”.Overallitisausefuland
veryhelpfulcontributiontotheliteratureofastillevolvingproblem.
Johanneshasaverybroadviewofallergicdiseasebutbringsspecial
expertisetoseveralareaswhichareoftenignoredorglossedover.Hehas
mademajorcontributionstoourknowledgeoftheroleofallergensin
atopiceczema.Inadditionhehasaprofoundknowledgeofotherforms
ofskindisease.Thisaddsdepthandexcellentjudgmenttotheopinions
expressed. He also includes a really useful chapter on pseudo-allergic
X Foreword
reactions.Thisisanimportantpartofdrugallergyandonetowhichhe
hasoftencontributed.Itisperhapstheawarenessofotherrashes,pseu-
do-allergicreactionsandanaphylactoidreactionsthataddsthegreatest
strengthtothebook.
InthelastfewyearsJohannesandhiscolleagueshaveestablishedthe
“Centerforallergy andenvironment” (ZAUM –ZentrumAllergieund
Umwelt)inMunich.Thisinstitutewhichisonlyfiveyearsoldhasalready
madeitsmark.Dr.Behrendt’sworkontheinteractionbetweenairpol-
lutantsandallergenparticlesiswellknownbutthisgroup’sworkona
groupofleukotrienelikemoleculesderivedfrompollenhasopenedupa
new area of allergy research. All this adds further depth to Dr. Ring’s
understanding which is clearly evident in the book. Certainly those
chaptersareapleasure.
Notunexpectedly,JohannesRinghaswrittenanexcellentbookwhich
coversawiderangeofallergicdisease.Thebookprovidesacomprehen-
sivebutverywellplanneddescriptionofthediseasesthatareeithervery
common or just common. His pragmatism comes through in all he
writesresultinginareallyusefulguidetoanincreasinglycomplexfield.
ThomasA.E.Platts-Mills,MD,PhD,FRCP
OscarSwinefordJrProfessorofMedicine
DivisionHeadofAsthmaandAllergicDisease
Table of Contents
1 ClinicalManifestationandClassificationofAllergicDiseases 1
1.1 History.............................................. 1
1.2 ClinicalManifestationandDefinitionofAllergy ........... 2
1.3 ClassificationofAllergicDiseases ....................... 5
References ........................................... 7
2 PathophysiologyofAllergicReactions ................... 8
2.1 TheImmuneResponse ................................ 8
2.2 Antibodies........................................... 15
2.3 IgE-MediatedReaction ................................ 16
2.3.1 Mast-CellActivation .................................. 16
2.3.2 IgEandAtopy ........................................ 17
2.4 CytotoxicReactions(TypeII)........................... 18
2.5 ImmuneComplexReactions(TypeIII)................... 19
2.6 CellularHypersensitivity(TypeIV)...................... 19
2.7 LessFrequentTypesofAllergicReactions(TypesVandVI) 20
2.8 Pseudo-allergicReactions .............................. 20
2.9 MediatorsofAllergicReactions ......................... 20
2.9.1 Histamine ........................................... 20
2.9.2 Eicosanoids.......................................... 20
2.9.3 Leukotrienes ......................................... 23
2.9.4 Platelet-ActivatingFactor .............................. 23
2.9.5 Serotonin............................................ 24
2.9.6 ComplementSystem .................................. 24
2.9.7 MediatorsfromNeutrophilGranulocytes................. 25
2.9.8 MediatorsfromEosinophilGranulocytes ................. 25
2.9.9 Kallikrein-KininSystem ............................... 25
2.9.10 Tachykinins......................................... 26
2.10 SynopsisofMediatorReleaseandInactivation ............ 26
References ........................................... 27
3 GeneticsandEnvironmentintheDevelopmentofAllergy .. 30
3.1 GeneticsofAllergy.................................... 30
3.1.1 ClassicalGenetics..................................... 30
3.1.2 MolecularGenetics ................................... 31
References ........................................... 32
3.2 EpidemiologyofAllergicDiseases....................... 33
3.2.1 AtopicDiseases....................................... 33