Table Of ContentIMMUNOLOGICAL ASPECTS OF ALLERGY
AND ALLERGIC DISEASES
VOLUME 5
Clinical Aspects of Allergic Diseases
IMMUNOLOGICAL ASPECTS
OF ALLERGY
AND ALLERGIC DISEASES
Edited by E. Rajka and S. Korossy
VOLUME 1
Basic Concepts in Experimental Immunology
VOLUME 2
Methods in Experimental Immunology
VOLUME 3
Clinical Aspects of Autoimmune Diseases
VOLUME 4:
Clinical Aspects of Immune Pathology
VOLUME 5
Clinical Aspects of Allergic Diseases
VOLUME 6
Antigen-Antibody Reactions in Different Organs
VOLUME 7
Allergic Diseases of the Skin
VOLUME 8
Allergic Responses to Infectious Agents
IMMUNOLOGICAL ASPECTS
OF ALLERGY
AND ALLERGIC DISEASES
Edited by
E.RAJKA
and
S. KOROSSY
Department of Dermatology
Istvan Municipal Hospital
Budapest, Hungary
VOLUME 5
Clinical Aspects of Allergic Diseases
PLENUM PRESS • LONDON AND NEW YORK
© Akademiai Kiad6, Budapest 1976
softcover reprint of the hardcover 1s t edition 1976
Coedition
published by
Akademiai Kiad6, Budapest, Hungary
and
PLENUM PUBLISHING CORPORATION
227 West 17th Street, New York N. Y. 1O0ll, U.S.A.
ISBN-13: 978-1-4615-7242-8 e-ISBN-13: 978-1-4615-7240-4
DOl: 10.1007/978-1-4615-7240-4
All rights reserved
No part of this publication may be reproduced in any
form without written permission from the Publisher
Library of Congress Catalog Card Number 75-34966
LIST OF CONTRIBUTORS
TO VOLUME 5
SANDOR GERO, M.D., D.Sc. (med.)
Retired Head of the 3rd Department of Medicine, Semmel
weis University Medical School, Mezo 1. lit 15-17., 1081
Budapest, Hungary
KAROLY HAJos, M.D., D.Sc. (med.)
Retired Head of the Department of Allergology, National
Institute of Rheumatology and Physiotherapy, Frankel
L. u. 25., 1027 Budapest, Hungary
MARIA K. HAJOS, M.D., C.Sc. (med.)
Head, Department of Allergology, National Institute of
Rheumatology and Physiotherapy, Frankel L. u. 25.,
1027 Budapest, Hungary
ARTHUR HAMORI, M.D., C.Sc. (med.)
Professor and Head, 2nd Department of Medicine, Pecs
University Medical School, Szechenyi ter 5., 7621 Pecs,
Hungary
LASZLO MOSONYI, M.D., C.Sc. (med.)
Professor and Head, 4th Department of Medicine, Post
graduate Medical School, Szabolcs u. 33., 1135 Budapest,
Hungary
v
PAr. OSVATH, M:D., C.Sc. (med.)
Head, Department of Paediatrics, Buda Regional Hospital,
Cserje u. 11., 1025 Budapest, Hungary
JUDIT SZEKELY, M.D., C.Sc. (med.)
Head, 2nd Department of Medicine, Koranyi Hospital,
Alsoerdosor 7., 1074 Budapest, Hungary
VI
CONTENTS OF VOLUME 5
Chapter 50
Allergic diseases of the respiratory tract
by K. Haj6s and M.-K. Haj6s .................. 1
Chapter 51
Allergic diseases of the lung parenchyma
by P. Osvath ................................. 85
Chapter 52
Allergic diseases of the digestive system
by L. Mosonyi ................................ 111
Chapter 53
Allergic renal diseases
by A. Hamori '" . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 171
Chapter 54
Allergic and autoimmune diseases of the heart
and great vessels
by S. Gero and J. Szekely ............ ........ 227
Index ....................................... 243
VII
CHAPTER 50
ALLERGIC DISEASES OF THE RESPIRATORY TRACT
by
K. RAJOS and M.·K. RAJOS
Part I
Allergic rhinit,is
Allergic diseases of the nasal cavity and paranasal sinuses
Diagnosis
Vasomotor rhinitis
Diagnosis
Treatment
Part II
Ray fever (pollinosis)
Aetiology and pathogenesis
Chemical and biological properties of the pollen allergen
Symptoms
Diagnosis
Treatment
Part III
Bronchial asthma in adults
Introduction
Pathology, mortality
Problems of terminology and classification
Aetiology and pathogenesis
Experimental asthma
The role of eosinophil leukocytes
Iso-ionic, blood-gas tension, water balance, and biochemical changes
The role of the digestive system
The role of neuroendocrine regulation
Exogenous (extrinsic) and endogenous (intrinsic) allergens
Non-allergic provocation of asthma
Immunoglobulins, reagins, blocking antibodies
Chemical mediat,ors
p-adrenergic deficiency theory
Clinical manifestations
The types of clinical picture
Age-dependent forms of asthma
General examination scheme
Spirometric investigations
X-ray examination
Importance of the rhino-, laryngo-, and bronchological examinations
Identification of causative allergens
Differential diagnosis
Cardiac asthma
Prognosis of asthma
1
Treatment of bronchial asthma
A voidance of exposure to allergens
Symptomatic relief
Attempts to alter the atopic constitution
Clinical control of therapeutic results
Laboratory tests
Treatment of chronic asthma and status asthmaticus
Prevention of asthma and treatment of complications
General measures
Surgical interventions
Psychotherapy of asthmatic patients
Physicotherapy
References
Part 1
ALLERGIC RHINITIS
Allergic tissue reactions and consequent clinical symptoms may occur in any part
of the upper respiratory tract. Symptoms of different localization may be simul
taneously or alternately observed in the same patient [66b, 96d, 138]. Allergic
rhinitis is an exudative inflammation of the nasal passage occurring in atopic
persons in contact with air-borne allergen to which they are sensitive, caused
by local release of vasoactive substances in an immediate hypersensitivity reac
tion. The reaction is mediated by IgE antibodies. The characteristic symptom
complex includes sneezing, nasal congestion, and watery discharge as well as
conjunctival itching and often cough and mild bronchoconstriction. The occur
rence of nasal reactions to allergens introduced orally or parenterally or mediated
by other immunological mechanisms is clearly possible [159b], even likely, but
proof for such mechanisms is lacking.
ALLERGIC DISEASES OF THE NASAL CAVITY
AND PARANASAL SINUSES
The nasal cavity has a dual function, viz. its tissues are involved in respiration
and olfaction. Although allergic reactions may impair olfaction, the allergologist
is concerned mainly with the reactions causing respiratory disturbances.
The morphology of the nasal cavity is of prime importance in respiration, and
the structure of the tissues of the nasal cavity, particularly the mucous membrane
is affected by the allergic process. The pathologic changes evoked by allergic dis
eases in the upper respiratory tract may be reversible or irreversible. Reversible
oedema accompanying certain tissue reactions may disappear completely, while
chronic oedema may persist causing a lasting mechanical obstruction. The essen
tial features of tissue manifestations are often hardly recognizable, since infections
and primary inflammatory reactions may precede or accompany allergic changes,
obscuring the histological pattern of the latter.
While in allergic diseases the main feature of tissue alterations is the thickening
and hyalinization of the basement membrane of the upper respiratory mucosa
[104], chronic diseases of the nasal cavity (chronic rhinitis) and paranasal sinuses
2
(hyperplastic sinusitis) are characterized by changes involving primarily the tunica
propria, stroma, or the subepithelial layer, where oedema and eosinophil infiltra
tion are most frequently found. Swelling of the basement membrane and the
hyperplasia of the mucous glands significantly enhance oedema. When the stro
ma can no longer keep the fluid, the extended tissues form a prolapse or polyp.
Histologically the nasal polyp is a circumscribed mucosal protrusion with
chronic oedema, containing connective tissue soaked with fluid, and often shows
cystic degeneration. Polyps in the nasal cavity are most frequently seen in the
semilunar hiatus, in the orifices ofthe paranasal sinuses, projecting into the ethmoi
deal cells and maxillary sinus. The polyps contain varying amounts of oedema
fluid with sparse fibrous cells and few mucous glands.
From the point of view of allergic pathomechanism, nasal polyps may either
be the result of local allergic reaction or may cause, by narrowing the airways,
obstruction leading to allergic diseases of the upper respiratory tract. Nasal
polyposis is relatively more frequent in intrinsic asthma with rhinitis (18 per
cent) than in extrinsic asthma with rhinitis (6 per cent) [9]. These results would
indicate that prolonged mucous congestion and oedema from any non-allergic
causes (e.g. chronic infections) lead to the formation of nasal polyps. On the other
hand high local 19E concentratians were found in nasal polyp without fluid cor
responding serum 19E levels, arguing for the presence of local allergy [55,
290]. The stimulation and suppression of the immunologic release of chemical
mediators (histamine, SRS-A, eosinophil chemotactic factor of anaphylaxis)
from nasal polyps has been studied in vitro by Kaliner et al. [133, 134]. The anti
gen activated release of mediators is modulated by agents affecting the intracel
lular concentration of cyclic nucleotides.
Polyps of different origin must be distinguished also from a therapeutic point
of view.
Allergic polyps are usually covered by a pale, grayish, gelatinous oedema
fluid, while polyps of inflammatory origin have a coarser structure, their colour
is deep red, and are usually covered by pus. Allergic polyps contract upon treat
ment with adrenalin solution, while infectious, inflammatory polyps hardly change.
Cytological, histological and bacteriological examinations may be of help in
the diagnosis. The presence of eosinophils with mononuclears and plasma cells
always suggests allergic origin. Pepys and Duveen [214] have proposed the fol
lowing classification of the allergic diseases of the nasal cavity and polyposis:
(i) abnormalities associated with positive allergic cutaneous tests and allergic
manifestations in the patient's history; (ii) conditions with negative cutaneous
tests and allergic history; (iii) mixed forms, with simultaneous allergic and in
fectious changes.
Repeated examinations of secretion and blood are necessary for the establish
ment of the allergic or infectious origin of the reaction. Table 50-1 summarizes
the pathological changes most frequently observed in the upper respiratory
tract.
Histological examination in allergy reveals oedematous, swollen epithelium,
slightly thickened basement membrane, cystic degeneration, in the submucosa
eosinophilic infiltration with slight lymphocytic and plasmacytic involvement;
thickening of the basement membrane may be marked in bronchial asthma.
The intensity of staining in the ground substance is variable [72].
3
