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(Chest. 2001;119:120-127.)
© 2001 American College of Chest Physicians

Determinants of Allergen-Induced Late Bronchial Responses in Mild Asthmatics*

María J. Alvarez-Puebla, MD, PhD; Jose M. Olaguibel-Rivera, MD, PhD; Eduardo Urbiola-Marcilla, MD, PhD; Blanca E. Garcia, MD, PhD and Ana I. Tabar-Purroy, MD, PhD

* From the Allergy Department (Dr. Alvarez-Puebla), Hospital de León, León, Spain; and the Allergy Department (Drs. Olaguibel-Rivera, Garcia, and Tabar-Purroy) and Pathology Department (Dr. Urbiola-Marcilla), Hospital Virgen del Camino, Pamplona, Spain.

Correspondence to: María J. Alvarez-Puebla, MD, PhD, Puebla C/Padre Arintero, n°11, 1°C, 24001 León, Spain; e-mail: mapuebla{at}terra.es


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objective: To examine the baseline factors influencing the occurrence and magnitude of immediate- and late-phase responses in asthmatic patients after an allergen-induced bronchial provocation test (A-BPT).

Design: Cross-sectional analysis in a homogenous group of 31 mild, Dermatophagoides pteronyssinus-allergic patients with asthma.

Setting: Allergy Department, Hospital Virgen del Camino, Pamplona, Spain.

Interventions and measurements: Patients completed an asthma symptom questionnaire and underwent skin tests, sputum induction, and methacholine bronchial provocation test. The A-BPT was performed on a separate day. Sputum cell profile and eosinophil cationic protein (ECP), tryptase, albumin, and interleukin-5 levels were quantified in the entire sputum supernatant. Assays were done for eosinophils in blood, and/or ECP, and total and specific IgE levels in serum. Exposure to D pteronyssinus major allergens (Der p1 and Der 2) was measured by an assay based on monoclonal antibodies.

Results: A-BPT findings were positive in all patients, and late-phase responses were detected in 29%. Late responders were exposed to higher levels of Der p1 (p = 0.028), had greater levels of ECP (p = 0.007) and albumin (p = 0.019) in sputum, and showed a trend toward higher lymphocyte numbers (p = 0.053) in sputum than isolated early responders. The allergen-induced provocative dose that induced a fall in FEV1 values >= 20% from the postdiluent values correlated with bronchial hyperresponsiveness (r = 0.36). The late-phase response magnitude correlated with Der p1 exposure (r = 0.49) and showed a trend toward correlation with sputum ECP levels (r = 0.38).

Conclusion: Factors involved in the development of allergen-induced immediate- and late-phase responses are different. Allergen natural exposure might prime the infiltration of the airway by activated inflammatory cells enhancing the appearance and the severity of late-phase responses.

Key Words: airway inflammation • allergen bronchial provocation test • asthma • bronchial hyperresponsiveness • Dermatophagoides pteronyssinus • eosinophil cationic protein • eosinophils • late-phase response


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 

Allergen inhalation by sensitized asthmatic patients results in an immediate-phase reaction (IPR) occurring within minutes and resolving in 30 to 60 min. A percentage of patients also present a late-phase reaction (LPR) that usually begins 3 to 4 h after allergen inhalation. Mechanisms underlying the airway narrowing in both responses are radically different: IPR is mainly secondary to mast cells activation and is consistent with acute asthma, and LPR is thought to depend on the activation of airway inflammatory cells during the IPR.1 LPR is usually accompanied by a bronchial hyperresponsiveness (BHR) enhancement2 of unclear meaning since it precedes the inflammatory changes.3 Airway eosinophilic infiltration and BHR are characteristic of asthma in all its evolutionary stages4 ; thus, allergen-induced LPR has been proposed as a model to study the natural process occurring in asthma.

The occurrence of LPRs can be modified by viral respiratory infections,5 the airway circadian rhythm,6 sensitization to perennial allergens in contrast to seasonal ones,7 treatment with antiasthmatic drugs, or by the equipment (particle size, delivery system) used in an allergen bronchial provocation test (A-BPT). When all these factors are controlled, the ability of individual subjects to elicit a LPR is reproducible.7 It is not clear to us why some subjects react to allergen inhalation with an isolated IPR, whereas others also present with a LPR. Asthma severity,8 the dose of allergen inhaled,9 the degree of sensitization10 and exposure11 12 to the allergen, the magnitude of the IPR,13 or the baseline BHR2 or airway inflammation14 15 has been directly associated with the occurrence of LPRs.

We analyzed the bronchial response pattern of a homogenous group of mild, Dermatophagoides pteronyssinus-allergic asthma patients to the A-BPT carried out under controlled conditions and in which known doses of Der p1 were inhaled. Our aim was to compare the groups according to the presentation of LPR with respect to several potentially influencing prechallenge factors (allergenic exposure and sensitization, BHR, and airway inflammation assessed in sputum and blood).


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
We studied 31 nonsmoking mild asthmatic patients (17 men and 14 women; age range, 19 to 29 years; median, 21 years) sensitized to D pteronyssinus who attended our allergy service. The diagnosis of asthma was made according to international guidelines.16 Only short-acting ß-agonists drugs used as needed were allowed in the previous 2 months. A history of respiratory symptoms lasting 12 to 24 months was required. No patient had a history of respiratory tract infections within the preceding 2 months. D pteronyssinus sensitization was established by positive skin prick tests with a standardized extract (ALK-Abelló; Madrid, Spain) and specific IgE (Pharmacia CAP System; Pharmacia Diagnostics; Uppsala, Sweden) to this allergen in the context of a compatible clinical history. Patients sensitized to other perennial (animal danders, molds) or seasonal (pollens) allergens were excluded. All subjects were informed and gave their consent before starting the study. The ethics committee of our hospital approved the study protocol.

Study Design
The study was developed in 2 separate days. First, patients underwent clinical and physical evaluation, cutaneous tests, and sputum induction. Samples of venous blood were collected. At least 8 h after sputum induction, the methacholine bronchial provocation test (M-BPT) was done. A sample of dust from the patients’ beds was collected, and subjects completed a standardized asthma symptoms questionnaire of which the validity and reproducibility had been demonstrated.17 The frequency of presentation of 10 bronchial symptoms (dyspnea during exercise, diurnal resting dyspnea, diurnal wheezing, diurnal cough, nocturnal wheezing, nocturnal dyspnea, nocturnal cough, sleep disturbance, asthma anxiety, and chest tightness) during the last month was scored from 0 (never) to 4 (every day) points. The total symptoms score ranged from 0 to 40 points. Patients underwent D pteronyssinus bronchial provocation testing on in a different day.

Allergen Extract
A D pteronyssinus partially purified and biologically standardized extract was used for skin and bronchial challenge tests (ALK-Abelló). Specific monoclonal antibodies were used to quantify Der p1 and Der 2 allergens. The final extract at 100 biological units/mL contained 40 µg/mL of Der p1 and 20 µg/mL of Der 2.

Collection of Dust Samples and Quantitation of Mite Allergens
Dust collection was made 7 days after the last cleaning, as previously described.18 A portable vacuum cleaner provided with a prefilter (ALK; Horsholm, Denmark), which retains 74% of particles 0.3 to 0.5 µm in size, 81% of particles 0.5 to 1.0 µm, 95% of particles 1.0 to 10 µm, and 100% of larger particles19 was used. The layer of bedding below the lower sheet, the layer above the upper sheet, and the area inside the pillowcase were vacuumed for 2 min per square meter. After vacuuming, the filter box was removed and stored at - 20°C until further analysis.

The content of major mites allergens (Der p1 and Der 2) was determined in duplicate by a commercial enzyme-linked immunosorbent assay (ELISA) based on monoclonal antibody (ALK). Standard curves for these assays (1 to 200 ng allergen/mL) were routinely obtained from freeze-dried whole-mite extracts titrated against purified allergens. Allergen concentrations were estimated from three independent experiments. The mean intra-assay coefficient of variation was < 3%, while the interassay coefficient of variation from control subjects tested in all the assays was < 15%. The detection limit of the assays was 1 ng/mL.

Skin Tests
Skin prick tests were carried out with a standard battery that included the most common airborne allergens in our area: mites, pollens, molds, and danders (ALK-Abelló). Tests were made by the same technician and the same lancets (ALK-lancet; ALK-Abelló) were used. Results were read at 15 min. Wheal diameters >= 3 mm were considered positive in the absence of response to phosphate-buffered saline solution (PBS). Histamine phosphate at 10 mg/mL and PBS were used as positive and negative controls.

We also skin tested the D pteronyssinus extract (containing 50% glycerine, 0.4% phenol and 0.9% NaCl) at three concentrations (60 µg/mL, 12 µg/mL, and 2.4 µg/mL of Der p1) in duplicate and in inverse direction. The resulting wheals were shaped and transferred to a millimeter-squared paper, where areas were measured and expressed in millimeters squared. We considered for analysis the mean value of the areas obtained from the six tests.

Bronchial Provocation Tests
Every lung function test was performed with the same spirometer (model CPR; Medical Graphics; St Paul, MN). Baseline spirometry was performed and FEV1 was recorded. FEV1 values >= 70% of predicted normal were required to start tests. Patients had not inhaled ß-agonist drugs for 8 h before the test. Methacholine or allergen extract was then administered by a dosimeter (MEFAR s.r.l.; MEFAR; Borezzo, Italy) programmed to deliver five inhalations of 1 s each. The dosimeter was always attached to the same nebulizer calibrated to deliver 10 µL of solution in each second. Patients were carefully instructed to slowly inhale the solution from the residual volume to the total lung capacity. Patients inhaled 10 µL of solution in each breath. Before starting the bronchial provocation test, patients inhaled diluent (PBS), and a variability in FEV1 values < 5% between baseline and postdiluent FEV1 values was required to start the bronchial provocation tests.

M-BPT
To avoid the circadian rhythm effect on airway dynamics, M-BPTs were performed between 2 PM and 4 PM. Methacholine (Provocholine; Roche Laboratory; Nutley, NJ) dilutions at 0.125, 0.25, 0.5, 1.0, 2.0, 5.0, 10.0, 25.0, 50.0, 100.0, and 200.0 mg/mL in PBS were made on the day. Methacholine at increasing concentrations was administered using the dosimeter, and FEV1 value was measured by spirometry 3 min later. The test finished when a fall in FEV1 values >= 20% from the postdiluent value was achieved, or when the highest concentration was inhaled. Results were expressed in terms of the provocative cumulative dose of methacholine needed to decrease FEV1 by 20% from the postdiluent value (M-PD20), where 1 mol methacholine = 195.4 g.

A-BPT
Every A-BPT was carried out between 8 AM and 10 AM. Baseline peak expiratory flow (PEF) rate was recorded before starting the test. Dilutions of the D pteronyssinus extract at 0.1, 0.25, 0.5, 1.0, 2.0, 5.0, and 10.0 biological units/mL in PBS were made on the same day of the test. Allergen dilutions at increasing concentrations were administered using the dosimeter, and FEV1 values were recorded 10 min later. The test finished when a fall in FEV1 values >= 20% from the postdiluent value was achieved, or when the highest concentration of allergen was inhaled. IPR results were expressed in terms of the provocative cumulative dose of allergen (in micrograms of Der p1) needed to decrease FEV1 by 20% of the baseline values (A-PD20). To record any late asthmatic reaction, PEF was measured hourly during the following 10 h. A late asthmatic reaction was considered as a fall of >= 25% from the basal value.20 LPR results were expressed as the maximal PEF rate decrease from the baseline values (expressed as percentage) and as the area under the time-response curve (measured by planimetry and expressed in centimeters squared).

Sputum Induction
Sputum samples were obtained by hypertonic saline solution inhalation as described.21 Subjects were pretreated with four puffs of inhaled salbutamol 30 min before induction. They rinsed their mouths and cleaned their noses before induction and, when possible, before expectoration. An ultrasonic nebulizer (Ultraneb 99; De Vilbiss; Somerset, PA) was used to administer saline solution at 5%, for three periods of 10 min. After each period, the patients were asked to cough and expectorate into a sterile container; when possible, saliva was put away in a different receptacle. The test was finished when a macroscopically adequate sputum sample was obtained or when the three periods of inhalation were completed.

The volume of the entire sputum sample was measured, and 3 mL of the entire sputum sample was mixed with an equal volume of dithiotreitol (Sputasol; Unipath LTD; Basingstoke, Hampshire, UK) at 1/100 and rocked at room temperature for 15 min. Then, the mixture was put through one 0.42-µm filter (Millipore; Somerset, PA) and centrifuged at 1,500g for 10 min. The supernatant was placed in aliquots and frozen at - 70°C until further analysis. The pellet was suspended in saline solution serum at 0.9%, and totals of cells were counted with a Fuchs Rosenthal chamber. The suspension was then cytocentrifuged and stained with either Papanicolau or Giemsa for differential cell counts. The sample was considered adequate for analysis when macrophages could be visualized and squamous cell contamination was < 20%.22 Percentage counts of macrophages, eosinophils, neutrophils, mast cells, and lymphocytes were made over a total count of 400 cells. A single person, blinded to the patients’ clinical conditions, performed the evaluation.

Soluble Markers in Sputum and Serum
The concentrations of eosinophil cationic protein (ECP) and tryptase in the sputum supernatant, and of ECP, and total and specific IgE in serum were measured with a fluoroenzyme immunosorbent assay (UniCAP; Pharmacia Diagnostics). Sputum interleukin (IL)-5 levels were determined in duplicate by a commercial "sandwich" ELISA (Quantikine; R&D Systems; Minneapolis, MN). Sputum albumin levels were measured in duplicate by automated nephelometry (Behring Diagnostics GmbH; Marburg, Germany). The limits of detection for the fluid-phase assays were 2.0 µg/L for ECP, 1.0 µg/L for tryptase, 0.35 kilounits/L for specific IgE, 2.0 kilounits/L for total IgE, 3.0 pg/mL for IL-5, and 1 mg/mL for albumin. Sputum chemistry results were referred to the sputum and dithiotreitol mix volume. All assays were performed blind to the clinical details.

Statistical Analysis
Statistical analysis of the data was performed using a statistics program (SPSS Windows 6.1; SPSS; Chicago, IL). Descriptive statistics were used to summarize the clinical and demographic characteristics of the patients. Log transformation was used to obtain normal distribution of data. Comparative analysis of means was carried out by the analysis of variance (t test for equality of means). Correlation between variables was determined with the Pearson’s rank correlation coefficient. We used one model of multiple linear regression model, in which the independent variables (allergen sensitization and exposure, M-PD20 and A-PD20 values, and inflammatory indexes in blood and sputum) were sequentially entered and applied to the dependent variable (presentation or not of a LPR). A p value of < 0.05 was considered significant.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
All the patients tolerated the A-BPT without complication and presented with IPRs. Nine subjects (29%) presented with a LPR. Comparison of groups was made according to the occurrence of LPR. Patients’ demographic data by group classification are listed in Table 1 . The mean area of skin tests (geometric mean [GM], 90.5 mm2 vs 86.7 mm2) and total and specific serum IgE did not differ between groups (Table 2 ). No differences between groups were found in values for baseline FEV1, M-PD20, and A-PD20 values (Table 2) or the cumulated doses of Der p1 inhaled during A-BPT (GM, 15.96 ng vs 18.11 ng). Late responders were exposed to higher Der p1 levels and showed a trend toward higher Der 2 levels (Fig 1 ).


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  		Table 1. Patient Demographic Characteristics*

 

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  		Table 2. Demographic Characteristics, Allergenic Exposure and Sensitization Indexes, Baseline Lung Function, and Response to A-BPT of the Patients Presenting With IPRs and LPRs*

 


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  		Figure 1. Comparison of Der p1 (left) and Der 2 (right) exposure levels between patients presenting with isolated IPRs and those presenting with LPRs.

 
Microscopically adequate sputum samples were obtained in all the cases; in most of them, ECP and albumin levels were detected (Table 3 ). Sputum tryptase identification rate was higher among patients presenting with LPR (66.7%), compared to those who did not (9.1%). There was a complete lack of detection of IL-5 in sputum. Late responders had higher sputum ECP and albumin levels, and showed a trend toward higher lymphocyte percentages in sputum (Fig 2 ). No difference in blood eosinophils or serum ECP levels was found between groups.


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  		Table 3. Individual Values and GMs of Eosinophils in Blood, ECP in Serum, and Cell Counts and Chemicals in Sputum From Patients Presenting With Isolated IPRs and LPRs*

 


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  		Figure 2. Comparison of the levels of ECP (top, left), albumin (top, right), and of the percentages of lymphocytes (bottom, left) in sputum between patients presenting with isolated IPRs and LPRs.

 
When the whole sample of patients was considered, no association between the magnitude of IPR and of LPR was found. A trend toward correlation was detected among A-PD20 values and total (p = 0.088; r = - 0.31) and specific serum IgE (p = 0.092; r = - 0.31). A-PD20 values correlated with M-PD20 values (p = 0.046; r = 0.36). Der p1 levels correlated with the maximal PEF fall during the LPR (p = 0.049; r = 0.44) and with the LPR area (p = 0.028; r = 0.49). Der 2 levels showed a trend toward correlation with both indexes (p = 0.078, r = 0.38 and p = 0.083, r = 0.38, respectively). No association between IPR severity and the inflammatory indexes in sputum or blood was found. Sputum ECP levels showed a trend toward correlation with the LPR area (p = 0.065; r = 0.38). When correlation was analyzed in the group of late responders, the percentage of eosinophils in sputum correlated with the LPR area (p = 0.011; r = 0.79) and with the maximal PEF fall during the LPR (p = 0.042; r = 0.68). The linear regression study showed that Der p1 levels contributed to the LPR severity (p = 0.021; r = 0.47). The addition of other variables (sensitization, M-PD20 values, A-PD20 values, or inflammatory indexes) did not modify the results.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
We have analyzed the factors that can influence the likelihood of developing an allergen-induced LPR in patients with monosensitized, mild, and stable asthma. The study was made under controlled conditions to exclude factors that can potentially alter the LPR or our measurement of it (circadian rhythm, respiratory tract infections, antiasthmatic drugs, equipment variations, and sensitization to other allergens). To reduce the effect of chronic inflammation and the remodeling process on the airway dynamics, we studied a group of patients with mild and short-duration asthma. A partially purified standardized D pteronyssinus extract was utilized in A-BPTs, and known amounts of Der p1 were inhaled according to the same dose schedule. The incidence of LPR in our study was lower than reported23 and what is attributable to the different indexes and criteria used to define it in the literature,20 and is in keeping with recent reports also utilizing high-quality allergenic extracts.24

Early studies suggested that duration and severity of asthma,8 allergen sensitization,10 degree of BHR,2 dose of inhaled allergen,8 or severity of the IPR13 was predictive of the response to the bronchial challenge. In our study, and in keeping with previous reports,24 25 26 such variables did not differ between isolated early and dual responders, and showed no association with the LPR severity. We only detected an association between BHR and the immediate response severity. This lack of differences between groups suggests that other factors should influence the occurrence of LPRs.

The level of exposure to house dust mite major allergens was higher in the patients who exhibited a late response; this is in agreement with indirect evidence, since it has been reported that A-BPT-dependent LPR appearance is enhanced by allergen exposure,27 and reduced by extreme allergen avoidance.12 It has also been shown that sustained inhalation of low doses of allergen, simulating natural exposure, is able to elicit LPRs in asthma25 and in rhinitis11 patients who previously were isolated early responders. Thus, it could be hypothesized that environmental allergen exposure might induce an activation state in the airway cells that would increase the response to allergen inhalation.

In this aspect, we studied the differences in the prechallenge sputum constituents between groups. We found that late responders were more likely to have detectable tryptase levels in sputum than isolated early responders. This is in keeping with the increased numbers of mast cells correlating with the magnitude of the LPR and has been shown in the BAL from dual responders.14 Since albumin is a marker of vascular leakage, and since activated mast cells release vasoactive mediators, the fact that late responders also had increased sputum albumin levels indirectly supports the existence of higher baseline mast cell activation in the airways from these patients.

Prechallenge sputum ECP levels also were higher in late responders, which is in keeping with studies28 performed on BAL samples obtained shortly after the A-BPT. In contrast with them,28 we did not detect more sputum eosinophils in the LPR group, which could be attributed to the time of measurement. The higher sputum ECP levels, and the correlation between the LPR magnitude and the sputum eosinophils detected in dual responders, suggest a higher eosinophilic activation in such a group. There is increasing evidence that lymphocytes play a central role in orchestrating the recruitment and activation of airway eosinophils29 ; in this aspect, we detected a trend toward higher sputum lymphocyte numbers among late responders. Since IL-5, released by lymphocytes30 and mast cells,31 is the major eosinophil-priming cytokine, we had expected to find higher levels of such cytosine in sputum from dual responders. Unfortunately, there was a complete lack of IL-5 detection, which might be attributed to the sample dilution or to the mildness of asthma; however, other authors have not detected IL-5 levels in sputum by using the ELISA technique.32 Otherwise, ILs (including IL-5) have been assessed in sputum samples by utilizing the polymerase chain reaction technique.33 Thus, in our opinion, the absence of IL-5 detection in this study is more likely a consequence of the method used to measure it than to the absence of IL-5 levels in sputum.

Both the level of exposure to house dust mite major allergens and the baseline airway inflammation were higher in the patients who exhibited a late response. Therefore, it could be hypothesized that the sustained exposure to a perennial indoor allergen might induce a baseline activation of airway cells. Such cells, through the release of mediators, might induce changes in the airway (mucosa edema, epithelium damage, smooth muscle hypertonicity). Although these changes are not relevant enough to influence asthma symptoms, lung function, or degree of BHR, they might determine that inhalation of large amounts of allergen, as happens during A-BPT, resulted in a larger late response.

We conclude that factors determining early and late asthmatic responses in patients with mild asthma are different. The immediate asthmatic response is related to the level of bronchial reactivity, and the late phase response, at least in part, is dependent on allergen exposure and prechallenge airway inflammation. Natural allergenic exposure might activate mast cells and eosinophils, inducing a "primed" airway that would respond to the allergen challenge with a higher occurrence and magnitude of late asthmatic responses.


   Footnotes
 
Abbreviations: A-BPT = allergen bronchial provocation test; A-PD20 = provocative dose of allergen that induces a fallin FEV1 values >= 20% from the postdiluent value; BHR = bronchial hyperresponsiveness; ECP = eosinophil cationic protein; ELISA = enzyme-linked immunosorbent assay; GM = geometric mean; IL = interleukin; IPR = immediate-phase response; LPR = late-phase response; M-BPT = methacholine bronchial provocation test; M-PD20 = provocative dose of methacholine that induces a fall in FEV1 values >=20% from the postdiluent value; PBS=phosphate-buffered saline solution; PEF = peak expiratory flow

This study was supported by research grants from the Departamento de Salud, Gobierno de Navarra, Fondo de Ayudas a Proyectos de Investigación, and from the Fundación de la Sociedad Española de Alergología e Inmunología Clínica. The authors thank Pharmacia Diagnostics for providing us with UniCAP tryptase kits, which made possible the measurement of protein. Additional support was provided by grants from the Spanish Association of Allergy and Clinical Immunology and by the Government of Navarra (Health Department).

Received for publication February 2, 2000. Accepted for publication August 2, 2000.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Sheth, KK, Lemanske, RF (1998) The early and late asthmatic response to allergen. Holgate, ST Busse, WW eds. Inflammatory mechanisms in asthma ,805-821 Marcel Dekker New York, NY.
  2. Cockcroft, DW, Ruffin, RE, Frith, PA, et al (1979) Determinants of allergen-induces asthma: dose of allergen, circulating IgE antibody concentration, and bronchial responsiveness to inhaled histamine. Am Rev Respir Dis 120,1053-1058[ISI][Medline]
  3. Durham, SR, Craddock, CF, Cookson, WO, et al (1988) Increases in airway responsiveness to histamine precede allergen-induced late asthmatic responses. J Allergy Clin Immunol 82,764-770[CrossRef][Medline]
  4. International Consensus Report on Diagnosis and Management of Asthma. International Asthma Management Project: definition, diagnosis and classification. Allergy 1992; 47(13suppl):1–61
  5. Calhoum, WJ, Swenson, CA, Dick, EC, et al (1991) Experimental rhinovirus 16 infection potentiates histamine release after antigen bronchoprovocation in allergic patients. Am Rev Respir Dis 144,1267-1273[ISI][Medline]
  6. Mohiuddin, AA, Martin, RJ (1990) Circadian basis of the late asthmatic response. Am Rev Respir Dis 142,1153-1157[Medline]
  7. Crimi, E, Brusasco, V, Losurdo, E, et al (1986) Predictive accuracy of late asthmatic reaction to Dermatophagoides pteronyssinus. J Allergy Clin Immunol 78,908-913[CrossRef][ISI][Medline]
  8. . et alShaver, JR, O’Connor, JJ, Pollice, M (1995) Pulmonary inflammation after segmental ragweed challenge in allergic asthmatic and nonasthmatic subjects. Am J Respir Crit Care Med 152,1189-1197[Abstract]
  9. Fish, JE, Aukin, MG, Kelly, JF, et al (1980) Comparison of responses to pollen extract in subjects with allergic asthma and nonasthmatic subjects with allergic rhinitis. J Allergy Clin Immunol 65,154-161[CrossRef][Medline]
  10. Boulet, LP, Roberts, RS, Dolovich, J, et al (1984) Prediction of the late asthmatic response to inhaled allergen. Clin Allergy 14,379-385[Medline]
  11. Koh, YY, Lim, HS, Min, KU, et al (1994) Airways of allergic rhinitis are primed to repeated allergen inhalation challenge. Clin Exp Allergy 24,337-346[Medline]
  12. Peroni, DG, Boner, AL, Vallone, G, et al (1994) Effective allergen avoidance at high altitude reduces allergen-induced bronchial hyperresponsiveness. Am J Respir Crit Care Med 149,1442-1446[Abstract]
  13. Peters, SP, Zangrilli, JG, Fish, JE (1997) Late phase allergic reactions. Middleton, E Reed, C Ellis, Eet al eds. Allergy: principles and practice (vol 1) ,342-355 Mosby San Louis, MO.
  14. Crimi, E, Chiaramondia, M, Milanese, M, et al (1991) Increased numbers of mast cells in bronchial mucosa after the late-phase asthmatic response to allergen. Am Rev Respir Dis 144,1282-1286[Medline]
  15. Aalbers, R, Kauffman, HF, Vrugt, B, et al (1993) Bronchial lavage and bronchoalveolar lavage in allergic-induced single early and dual asthmatics responders. Am Rev Respir Dis 147,76-81[ISI][Medline]
  16. Guidelines for the diagnosis and management of asthma. National Heart, Lung, and Blood Institute. National Asthma Education Program. Expert Panel Report. J Allergy Clin Immunol 1991; 88(3 pt 2):425–434
  17. Steen, N, Hutchinson, A, McColl, E, et al (1994) Development of a symptom based outcome measure for asthma. BMJ 309,1065-1068[Free Full Text]
  18. Platts-Mills, TAE (1992) Dust mite allergens and asthma: report of a second international workshop. J Allergy Clin Immunol 89,1046-1060[CrossRef][ISI][Medline]
  19. Dreborg, S, Einarsson, R, Lau, S, et al (1995) Dust sampling for determination of allergen content. Allergy 50,188-189[Medline]
  20. Spector, SL (1995) Allergen inhalation challenges. Spector, SL eds. Provocation testing in clinical practice ,325-368 Marcel Dekker New York, NY.
  21. Alvarez, MJ, Olaguibel, JM, García, BE, et al (2000) Airway inflammation in asthma and perennial allergic rhinitis: relationship with nonspecific bronchial responsiveness and maximal airway narrowing. Allergy 120,355-362
  22. Fahy, JV, Wong, H, Liu, J, et al (1995) Comparison of samples collected by sputum induction and bronchoscopy from asthmatic and healthy subjects. Am J Respir Crit Care Med 152,53-58[Abstract]
  23. Booij-Noord, H, De Vries, K, Sluiter, HJ, et al (1972) Late bronchial obstructive reaction to experimental inhalation of house dust mite. Clin Allergy 2,43-71[CrossRef][Medline]
  24. Haugaard, L, Iversen, M, Dahl, R (1997) Predictors of early and late phase reactions to bronchial allergen challenge. Allergy 52,999-1004[Medline]
  25. Ihre, E, Axelsson, IGJ, Zetterström, O (1988) Late asthmatic reactions and bronchial variability after challenge with low doses of allergen. Clin Allergy 18,557-567[CrossRef][ISI][Medline]
  26. Van der Ween, M, Lopuhaä, CE, Aalberse, RC, et al (1998) Bronchial allergen challenge with isolated major allergens of Dermatophagoides pteronyssinus: the role of patient characteristics in the early asthmatic response. J Allergy Clin Immunol 102,24-31[Medline]
  27. Koh, YY, Choi, JW, Lee, MH, et al (1997) A preceding airway reaction to one allergen may lead to priming of the responses to another allergen. Allergy 52,284-292[Medline]
  28. DeMonchy, JGR, Kauffman, HF, Venge, P, et al (1985) Bronchoalveolar eosinophilia during allergen-induced late asthmatic reactions. Am Rev Respir Dis 131,433-440
  29. Robinson, DS, Ying, S, Bentley, AM, et al (1993) Relationship among numbers of bronchoalveolar lavage cells expressing messenger ribonucleic acid for cytokines, asthma symptoms and airway methacholine responsiveness in asthma. J Allergy Clin Immunol 92,397-403[CrossRef][ISI][Medline]
  30. Egan, RW, Umland, SP, Cuss, FM, et al (1996) Biology of interleukin-5 and its relevance to allergic disease. Allergy 51,71-81[ISI][Medline]
  31. Galli, SJ, Costa, JJ (1995) Mast cell leukocyte cascades in allergic inflammation. Allergy 50,851-862[ISI][Medline]
  32. Louis, R, Shute, J, Biagi, S, et al (1997) Cell infiltration, ICAM-1 expression, and eosinophil chemotactic activity in asthmatic sputum. Am J Respir Crit Care Dis 155,466-472
  33. Gelder, CM, Thomas, PS, Yates, DH, et al (1995) Cytokine expression in normal, atopic and asthmatic subjects using the combination of sputum induction and the polymerase chain reaction. Thorax 50,1033-1037[Abstract]




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