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变应性鼻炎的特异性免疫治疗

变应性鼻炎的主要治疗方式是：避免接触变应原、药物治疗、免疫治疗。该病的治疗方法多种多样，但大多数是对症治疗，难以达到临床治愈的目的。随着免疫学的不断发展，变应性鼻炎标准化特异性免疫治疗作为阻断变应性疾病发展进程的治疗，在临床应用中取得了良好效果。现就如何规范免疫治疗过程及方法，重视不良反应的观察和处理，提高患者的依从性等进行介绍。

变应性支气管肺曲霉病合并肺诺卡菌感染一例并文献复习

目的提高对变应性支气管肺曲霉病（allergic bronchopulmonary aspergillosis，ABPA）合并诺卡菌感染的认识。方法回顾我科诊断的1例ABPA合并诺卡菌感染的临床资料，结合文献复习ABPA和诺卡菌病的宿主特征、临床表现、影像特点等。结果患者男，79岁，退休工人，咳嗽、咳痰、喘息、胸闷20余年，有影像资料记录至少漏诊ABPA 6年。血嗜酸性粒细胞计数和比例升高，血清总IgE升高，胸部CT表现为中心型支气管扩张和浸润影，诱导痰中性粒细胞和嗜酸性粒细胞比例升高，肺泡灌洗液淋巴细胞和嗜酸性粒细胞比例升高，灌洗液mNGS、灌洗液和痰培养证实有诺卡菌和烟曲霉。给予糖皮质激素、伏立康唑、伊曲康唑和复方磺胺甲噁唑治疗，短期内临床症状减轻，血嗜酸性粒细胞下降，肺部影像有所好转，但血清总IgE无明显下降。复习文献，有3例个案报道。其中，2例ABPA治疗中继发诺卡菌感染，与应用糖皮质激素治疗引起免疫抑制有关，1例确诊ABPA前应用多种抗生素引起诺卡菌“二重感染”。结论ABPA和诺卡菌病的免疫状态不同，前者引起的支气管扩张可能是合并诺卡菌感染的危险因素。

Systematic Review of the Safety of Steroids for Chronic Sinusitis/Nasal Polyps and Allergic Rhinitis

Objective　To evaluate the safety of intranasal use of beclomethasone dipropionate, budesonide, fluticasone propionate and mometasone for adults and children with chronic sinusitis/nasal polyps and allergic rhinitis. Methods　Randomized controlled trials were located. Study quality was evaluated by two researchers independently. RevMan 4.2 was used for meta-analysis. Results　Seven RCTs involving 826 patients were included. Compared with placebo, local use of fluticasone proprionate in adults showed no statistically significant trend to increase incidence of acute sinusitis (OR 16.87, 95% CI 0.87 to 301.62), but no significant difference was seen for epistaxis (OR 7.76, 95% CI 0.38 to 157.14): 1 trial, 60 patients. In another trial, no cases of nasal atrophy were reported in either fluticasone or placebo groups. No significant differences were seen between local use ofbudesonide and placebo in adults for dryness of nasal mucosa (OR 3.38, 95%CI 0.66 to 17.18) and epistaxis (OR 2.20, 95%CI 0.39 to 12.32): 1 trial, 193 participantions. No significant difference was seen between budesonide and pollinex for headache (OR 1.71, 95%CI 0.52 to 5.62). No differences were seen between placebo and fluticasone propionate in children for epistaxis (OR 0.85, 95%CI 0.20 to 3.66), headache (OR 0.25, 95%CI 0.02 to 2.83), plasma cortisol concentration (OR 1.56, 95%CI 0.06 to 38.69) and dryness of nasal mucosa (OR 4.76, 95%CI 0.25 to 89.54). Beclomethasone dipropionate in children showed no statistical differences for dryness of nasal mucosa (OR 0.51, 95%CI 0.14 to 1.87), epistaxis (OR 0.68, 95%CI 0.26 to 1.73) and rhinitis (OR 0.47, 95%CI 0.04 to 5.36). No decrease of plasma cortisol concentration was detected in either group. Mometasone and placebo showed no significant differences in children for epistaxis (OR 1.57, 95%CI 0.41 to 5.95), rhinitis (OR 0.33, 95%CI 0.01 to 8.22) or headache (OR 0.33, 95%CI 0.01 to 8.22). Decrease of plasma cortisol concentration was not detected. Conclusions　According to this systematic review, long term intranasal use of steroid for adults and children may be safe based on the two high quality, four moderate quality trials and one with b bias. High quality studies with larger sample sizes and in other languages are needed to provide ber evidence.

Dust Mite Sublingual Immunotherapy for Allergic Rhinitis: A Meta-Analysis

Objective　To assess the effectiveness of dust mite sublingual immunotherapy (SLIT) for treating allergic rhinitis. Methods　The randomized controlled trials (RCTs) about SLIT treating allergic rhinitis were collected in MEDLINE, EMbase, The Cochrane library (Issue 10, 2012), CNKI, VIP, WanFang Data and CBM from inception to October, 2012. Two reviewers independently screened the literature according to the inclusion and exclusion criteria, extracted the data, and assessed the quality, and then the meta-analysis was performed by using RevMan 5.1 software. Results　A total of 8 RCTs involving 788 patients were included. The results of meta-analysis showed that, compared with the control group, SLIT showed no obvious difference in the total effective rate (RR=1.15, 95%CI 0.88 to 1.50, P=0.29), but it was superior in decreasing the scores of both nasal symptom (SMD= −1.13, 95%CI −2.07 to −0.20, P=0.02) and drug intake (SMD= −0.60, 95%CI −1.06 to −0.15, P=0.009). Conclusion　SLIT can improve the symptoms of patients with allergic rhinitis, and it can also decrease the using frequency of antihistamine, beta-blocker and nasal spray steroids.

Efficacy and Safety of Dust Mite Sublingual Immunotherapy for Pediatric Allergic Rhinitis: A Meta-Analysis

ObjectiveTo systematically review the efficacy and safety of dust mite sublingual immunotherapy (SLIT) in the treatment of children with allergic rhinitis. MethodsRandomized controlled trials (RCTs) about SLIT treating allergic rhinitis in pediatric patients was searched in PubMed, EMbase, CBM, Ovid, The Cochrane Library (Issue 5, 2014), CNKI, VIP and WanFang Data from inception to May 2014. Two reviewers independently screened literature according to inclusion and exclusion criteria, extracted data, and assessed methodological quality of included studies. Then meta-analysis was conducted using RevMan 5.3 software. ResultsA total of nine RCTs including 663 patients were finally included. The results of meta-analysis indicated that:the trial group was superior to the control group in reducing the scores of drug use (SMD=-0.61, 95%CI-0.94 to-0.27, P=0.000 4) and mite-specific serum IgE levels (follow-up time > 22 weeks:SMD=0.71, 95%CI 0.31 to 1.12, P=0.000 5). However, no significant difference was found between the two groups in the scores of nasal symptoms (SMD=0.06, 95%CI-0.13 to 0.25, P=0.55) and the incidence of adverse reaction (OR=1.3, 95%CI 0.89 to 1.90, P=0.17). ConclusionSLIT could decrease the use frequency of antihistamine, β-agonist and nasal spray steroids, and it has less adverse reaction and better safety in the treatment of children with allergic rhinitis. But SLIT could neither effectively alleviate nasal symptoms nor reduce mite-specific serum IgE levels of pediatric patients with allergic rhinitis in a short time.

嗜酸性粒细胞肉芽肿性血管炎相关的Purtscher样视网膜病变1例

Clinical Analysis of Four Cases of Allergic Bronchopulmonary Aspergillosis and Literature Review

ObjectiveTo investigate the clinical manifestations, diagnosis and treatments of allergic bronchopulmonary aspergillosis (ABPA). MethodsThe clinical data of four cases of ABPA diagnosed in our department between 2009 and 2014 were analyzed. The related literature was also reviewed. ResultsABPA tends to occur in people with chronic lung diseases, such as asthma and cystic fibrosis. The main clinical manifestations are wheezing, fever, cough, and sputum production. Laboratory examinations include immediate Aspergillus skin test reactivity, elevated total serum IgE and Aspergillus specific IgE and IgG antibodies, and peripheral blood eosinophilia. Radiological findings include recurrent chest roentgenographic infiltrates and central bronchiectasis. Treatments involve corticosteroids and antifungal therapy with itraconazole. ConclusionsABPA is easy to misdiagnosis clinically. It should be considered in patients with poor controlled asthma and asthmatic patients with acute pulmonary infiltrates. Early diagnosis and proper treatment can minimize lung injury from ABPA and improve outcomes.

变应性肉芽肿性血管炎两例并文献复习

变应性肉芽肿性血管炎又称Churg—Strauss综合征(CSS )，是一种以哮喘、血和组织中嗜酸粒细胞增多、血管外坏死性肉芽肿为特征的系统性小血管炎。该病临床罕见，国外报道其发病率约为24/100万。由于该病早期临床表现不典型，容易误诊，现将我院收治的2例CSS患者报告如下。临床资料 例1 患者男性，56岁。因“反复胸闷气喘伴咳嗽28个月，双手发麻6个月，加重10 d”，于2007年12月1日入院。2005年8月起无明显诱因经常感胸闷气喘，活动时明显，伴咳嗽，咳少量白色黏痰，在外院诊断为肺炎，经抗感染治疗可好转。2006年6月2日胸部CT示两肺纹理粗乱，右中叶、左舌叶见少许小片状影；2006年6月6日支气管镜检查见气管支气管黏膜充血水肿，腔内少量白色分泌物；痰找抗酸杆菌阳性，于2006年6月7日第1次住院。病程中，体重减轻10 kg。既往于2005年5月22日因双侧锁骨上窝淋巴结肿大行淋巴结活检，活检病理示慢性反应性增生；1:2000 PPD试验 红肿大小为10 mm×11 mm，有水泡。查体:双肺未闻及干湿性啰音。入院后查血常规：白细胞（WBC）总数11.1×109/L，血红蛋白96 g/L，血小板计数192×109/L；血结核抗体弱阳性（酶标法）；肝功能：球蛋白82.1 g/L，白蛋白28.3 g/L；肾功能正常；血沉 115 mm/1 h；尿常规：潜血（±），痰找结核菌6次阴性；腹部CT平扫+增强提示右肾上腺肿瘤（嗜铬细胞瘤可能性大）；心脏彩超及动脉血气正常。诊断为肺结核，支气管结核，右肾上腺嗜铬细胞瘤，于2006年6月19日予3HLEZ/9HL方案抗结核及抗感染治疗，2006年6月26日症状好转出院，但仍感活动时胸闷气喘，复查血常规：WBC总数8.3×109/L，血红蛋白95 g/L，血小板计数400×109/L；肝功能：球蛋白68.5 g/L，白蛋白26.3 g/L；肾功能正常。于2006年9月1日因双下肢关节痛自行停用抗结核治疗。2006年9月11日行右肾上腺嗜铬细胞瘤切除治疗。

真菌蛋白酶在变应性哮喘发病中的作用

近年来, 支气管哮喘的发病率在许多国家均呈上升趋势, 带来沉重的经济和社会负担 。许多研究表明, 室内真菌和变应性哮喘之间存在着密切关系, 给予对真菌存在免疫学致敏的哮喘患者抗真菌治疗能够改善症状, 提高生活质量。目前对于室内真菌引起变应性哮喘的详细机制还远未阐明, 本文主要论述真菌蛋白酶在变应性哮喘中的可能作用。

Epidemiology Study of Allergic Diseases in Liangshan District

【摘要】　目的　调查凉山地区青少年四种常见变应性疾病——湿疹、荨麻疹、变应性鼻炎（allergic rhinitis，AR）、支气管哮喘（bronchial asthma，BA）的发病情况，及农村与城区患病差异。　方法　采用分层整群抽样方式确定调查点。受调查者填写调查问卷，接受皮肤科、耳鼻喉科、内科专科医师检查。　结果　湿疹调查8 113人，发现患者810例，患病率10.0%，标准化患病率9.3%；男性患病率8.1%，女性患病率11.2%（Plt;0.01）；城区与农村患病率均为10.0%。荨麻疹调查8 113人，发现患者513例，患病率6.3%，标准化患病率6.5%；男性患病率4.6%，女性患病率7.5%（Plt;0.01）；农村患病率6.9%，城区患病率4.9% （Plt;0.01）。AR调查7 977人，发现患者741人，患病率9.3%，标准化患病率9.1%；男性患病率9.4%，女性患病率9.2%（Pgt;0.05）；农村患病率9.0%，城区10.1%（Pgt;0.05）。BA调查7 741人，发现患者296例，患病率3.8%，标准化患病率4.0%；男性患病率3.2%， 女性患病率4.2%（Plt;0.05）；农村患病率4.1%，城区患病率2.9%（Plt;0.05）。　结论　通过调查获得了凉山地区青少年四种变应疾病患病数据。发现女性湿疹、荨麻疹、BA患病率均高于男性，AR患病率相近。农村湿疹、荨麻疹、支气管哮喘患病率均高于城区，AR患病率相近。【Abstract】　Objective　To obtain the prevalence rate of four common allergic diseases, including eczema, urticaria, allergic rhinitis, and bronchial asthma, in adolescent of Lianshan district; and to explore the differences of these allergic diseases prevalence rate between rural area and urban area.　Methods　A survey was conducted in adolescent. The cluster sampling was used. The subjects were required to fulfill the self-report questionnaires and also received physical examinations by doctors.　Results　A total of 8 113 individuals were included in eczema studis, in whom eczema were present in 810 with a morbidity of eczema of 10.0% (9.3% after standardized). The prevalence rate of eczema in males and females were 8.1% and 11.2%, respectively (Plt;0.01). The prevalence rate of eczema in urban area was the same as that in rural area (10.0%). A total of 8 113 people were included in the urticaria study, in whom urticaria were found in 513. The prevalence rate was 6.3% (6.5% after standardized). The prevalence rate of urticaria in males and females were 4.5% and 7.6%, respectively (Plt;0.01), and were 6.9% and 4.9% respectively in rural area and urban area (Plt;0.01). A total of 7 977 people were included in AR studis. AR was present in 741 people, and the prevalence rate of AR was 9.3% (9.1% after standardized). The prevalence rate of AR in males and females were 9.4% and 9.2% respectively (Pgt;0.05), and were 10.1% and 9.0% respectively in urban area and rural area (Pgt;0.05). A total of 7 741 people were included in BA study, and BA were present in 296 people. The prevalence rate of BA were 3.8% (4.0% after standardized). The prevalence rate in males and females were 3.2% and 4.2% respectively (Plt;0.05), and were 2.9% and 4.1% respectively in urban area and rural area (Plt;0.05).　Conclusion　The prevalence rate of these commom allergic diseases in adolescent of Liangshan district was obtained. The females have a higher prevalence rate of eczema, urticaria and BA than that in the males; the prevalence rate of AR in males is similar to which in the females. A higher prevalence rate of eczema, urticaria and BA is found in rural area than that in urban area; the prevalence rate of AR in urban area is similar to which in rural area.