Вы находитесь на странице: 1из 5

Clinical Improvement of Asthma after Anthelminthic

Treatment in a Tropical Situation


NEIL R. LYNCH, MIGUEL PALENQUE, ISABEL HAGEL, and MARIA C. DIPRISCO
Instituto de Biomedicina, Facultad de Medicina, Universidad Central de Venezuela, Caracas; and Clinica Experimental de Asma,
FONDENE, Isla de Coche, Venezuela

Intestinal helminths are among the most common infectious organisms of humans, particularly in
tropical regions, and can induce the production of large quantities of IgE antibody. Part of this re-
sponse is directed against the helminths own antigens, but a polyclonal stimulation also occurs that
may increase the allergic reactivity toward environmental allergens. The importance of this in the
symptomatology of asthma in these regions is, however, uncertain. In the present study we evalu-
ated the effect of regular anthelminthic treatment with albendazol for 1 yr on a group of asthmatic
patients in a zone in which these parasites are endemic. The number of asthmatic crises, need for
maintenance therapy with inhaled steroids, and use of inhaled b2-agonists were compared both with
those in the year prior to the study for the treated patients, and with those in a group of asthmatic
subjects evaluated in parallel, but in whom the parasitic infections were not controlled. Significant
improvement in all of these indicators of clinical status occurred in the treated group, not only for the
period of anthelminth administration, but also for the year following. However, after 2 yr without
treatment, the severity of asthma reverted to the initial state. No significant changes were observed
in the control group over the entire period of evaluation. At the beginning of the study, the patients’
pulmonary function was below the levels predicted for normal individuals, but this was not changed
by the anthelminthic treatment. The patients’ total serum IgE levels, which were elevated at the be-
ginning of the study, were significantly diminished by the anthelminth administration, as were the
specific IgE antibody levels and positivity in skin tests for immediate hypersensitivity to the common
environmental allergen Dermatophagoides sp. However, the specific response to Ascaris lumbricoides,
a common helminth in the area, was maintained despite treatment. These results indicate that intes-
tinal helminthic infections can contribute to the clinical symptoms of asthma in an endemic situation.
This may occur via a direct response to the parasite and/or a nonspecific potentiation of allergic reac-
tivity to environmental allergens. Lynch NR, Palenque M, Hagel I, DiPrisco MC. Clinical improve-
ment of asthma after anthelminthic treatment in a tropical situation.
AM J RESPIR CRIT CARE MED 1997;156:50–54.

Helminthic parasites provide particularly potent stimuli for tion of IgE synthesis (8, 9). Helminthic infections of low inten-
the synthesis of IgE antibody (1), and the existence of allergic- sity can nonspecifically potentiate the synthesis of IgE anti-
type reactivity to these organisms is well recognized (2). In ad- body against environmental allergens, and thus enhance
dition, immediate hypersensitivity skin-test reactions to ex- allergic reactivity (10–13). In contrast, the excess polyclonal
tracts of these parasites are very common in situations in IgE stimulated by more intense helminthic infection can sup-
which such infections are endemic (3). For a number of years, press the allergic response by producing mast-cell saturation
however, controversy has surrounded both the possible in- (14) and inhibition of specific IgE antibody synthesis (3, 7). In
volvement of helminthic infection in the pathogenesis of respi- previous studies, we have demonstrated a direct relation be-
ratory disease (4–6) and its influence on the prevalence of al- tween helminthic infection and pulmonary function. Thus,
lergic conditions in the tropical environment (3, 7). This may bronchial challenge with helminth extracts can induce bron-
be at least partly due to the ability of these parasites to also choconstriction in clinically asthmatic children in areas in which
cause an interleukin-4 (IL-4)-dependent polyclonal stimula- helminthic infection is endemic (15). Also, nonasthmatic chil-
dren in such areas can respond significantly to bronchodilator
(Received in original form June 19, 1996 and in revised form March 10, 1997)
inhalation, and this response can be reversed by anthelminthic
treatment (16). Moreover, parasite eradication can produce a
Supported by Consejo Nacional de Investigación Cientifica y Tecnológica RPV
170041, Consejo de Desarrollo Cientifica y Humanistica/Universidad Central de reactivation of allergic reactivity toward common environmen-
Venezuela, Congreso de la Republica/Ministerio de Educación/UCV, World Bank tal allergens in children in whom this is suppressed by exces-
grant VEN/96/002/14, and grant SD.000.0309 from Astra-Draco, Sweden. sively polyclonal IgE (17).
Correspondence and requests for reprints should be addressed to Dr. Neil Lynch, Considering the complexity of the possible influence of hel-
Instituto de Biomedicina, Aptdo. 4043, Carmelitas, Caracas, 1010A, Venezuela. minthic infection on allergic reactivity, we evaluated in the
Am J Respir Crit Care Med Vol. 156. pp. 50–54, 1997 present study the effect of regular and prolonged anthelmin-
Lynch, Palenque, Hagel, et al.: Helminthic Infection and Asthma 51

thic treatment on a group of clinically asthmatic patients in a Management of Asthma


tropical environment in which these parasites are endemic. As The strategy for asthma management employed in the asthma clinic is
the intensity of infection in this group was low to moderate, maintenance inhalation of beclomethasone (100 mg twice daily), com-
we hypothesized that such treatment would improve the pa- plemented with inhaled salbutamol (200 mg as needed) when signifi-
tients’ clinical condition either: (1) by removing the specific al- cant symptoms (cough, dyspnea, wheezing) occur. If this treatment
lergic stimulus exerted by the parasites at the level of the lung; was not sufficient to control asthmatic episodes in the patients in the
(2) by decreasing the potentiating effect that helminthic infec- study, they were treated as outpatients in the asthma clinic, receiving
intravenous methylprednisolone (1.5 mg/kg) and nebulized fenoterol
tion might have on the synthesis of IgE antibody against com-
(250 mg) and ipratropium bromide (125 mg). If asthmatic crises oc-
mon environmental allergens, such as house-dust mite; or (3) curred more than twice monthly, the beclomethasone used for main-
both. tenance treatment was changed to inhaled budesonide (200 mg twice
daily). When a patient was symptom-free for a period of 3 mo, the
METHODS maintenance treatment was suspended, and was resumed if symptoms
reappeared. Because of the cost of the asthma medication, the asthma
Asthmatic Patients clinic was the only source of treatment available to the patients, and
The study was performed on a total of 89 asthmatic patients (age: we were therefore able to accurately monitor the consumption of these
18.5 6 14.6 yr [mean 6 SD]; 48% male and 52% female), who for a drugs over the year prior to the commencement of the treatment pe-
number of years had attended the asthma clinic established by the riod (designated Year 0), and for Years 1 to 3 of the study. We should
Fund for the Development of the State of Nueva Esparta (FONDENE) note here that the day-to-day clinical management of the patients was
on Coche Island, Venezuela. The patients were all of very low socio- the responsibility of short-term interns who staffed the medical dis-
economic level, being classified as in a condition of “critical poverty” pensary, and who were not aware of the objective of the study. They
according to the scale in official use in Venezuela (18). Because the were, however, informed that the patients were receiving albendazol.
clinic belongs to the only medical facility on the island, and provides
treatment free of charge, the patients do not seek attention elsewhere.
The only criteria applied in the selection of these patients was that Evaluation of Pulmonary Function
they had active asthma, were experienced in the performance of pul-
As part of the routine clinical management of patients by the asthma
monary function tests, and agreed to participate in the full study pro-
clinic, tests of pulmonary function are regularly given by the resident
gram. At the outset of the study, 100 patients were selected, 50 of
chest physician (Dr. M. Palenque) to all patients in the control pro-
whom were randomly assigned to the treatment group and 50 to the
gram, following the guidelines of the American Thoracic Society
untreated control group. Of the former, 10 were excluded from the fi-
(ATS) (19). For the purpose of our study, pulmonary function was
nal analysis because of noncompliance with the treatment protocol. In
measured immediately prior to the beginning of the study (Year 0)
one treated patient, two mild asthmatic episodes closely followed al-
and again at the end of Year 1, using a Respiradyne II solid-state
bendazol administration. Although it was uncertain whether this oc-
spirometer (Sherwood Medical, St. Louis, MO). The values of FVC,
curred by chance, or was due to the anthelminthic agent, this patient
FEV1, peak expiratory flow rate (PEFR), and maximum midexpira-
was also withdrawn from the study.
tory flow (MMEF) rate were calculated. Because many of the patients
were children, the absolute spirometric values at the beginning and
Ethical Considerations end of the study period could not be directly compared. For this rea-
The study protocol was approved by the ethical committee of the In- son, they were expressed as percentages of the values predicted ac-
stitute of Biomedicine of the Central University of Venezuela and the cording to the height and sex of the patients, using normal values de-
administrative medical staff of the Coche Island medical dispensary termined for a group of Spanish subjects (20), or as the FEV1/FVC
Venezuelan Ministry of Health and Social Assistance, to which the ratio, also expressed as a percentage. Prior to the study, the bronchial
asthma clinic is attached. It was also ratified by the National Council hyperreactivity (BHR) of the patients was confirmed by bronchial
for Scientific and Technological Investigation (CONICIT) of Venezu- provocation with histamine (21), in which 1 ml of histamine base (as
ela. The investigative procedures applied were part of the routine dihydrochloride; Sigma Chemical Co., St. Louis, MO) was nebulized
evaluation and follow-up program of the asthma clinic, which up to in stepwise concentrations from 0.0081 mg/ml to 5.0 mg/ml. Changes
the time of the study did not include rigorous control of parasitic in- in FEV1 of > 20% (PC20) at a histamine concentration < 2.5 mg/ml
fection in its patients. In this respect, the control group was not de- were considered to indicate a state of BHR. This test was repeated at
prived of the right to receive anthelminthic treatment, but rather this the end of Year 1. All asthma medication was suspended on the day
was formally implemented in the treated group on a regular basis. Be- before the testing of pulmonary function. We should point out here
cause of the low socioeconomic level and correspondingly limited that this aspect of the evaluation was not performed in a blind man-
medical awareness of the patients, the administration of a placebo to ner, since the chest physician was aware of the objectives of the study.
the control group was not considered acceptable by the members of In a group of 10 asthmatic patients of higher socioeconomic level
the community. Instead, we received ethical permission to inform the on a neighboring island (Margarita Island), and in whom helminthic
treated group of our objective of controlling their helminthic infec- infection was not endemic, pulmonary function tests were performed
tions without specifically explaining to them the hypothesis of the before and then again at 1 and 24 h after the administration of al-
study that their asthma would also improve with such control. bendazol, to determine whether this affected their pulmonary func-
tion. Although the data for this group are not presented here, we
Anthelminthic Treatment found that this treatment had no bronchodilator effect.
Albendazol (400 mg) was administered monthly for a period of 1 yr to
the treated group. Since the patients were in a situation of endemic
helminthiasis, treatment was administered irrespective of the results Parasitologic Examination
of the initial fecal examination, and the anthelminthic agent was ad- Three serial fecal samples were collected into preservative solution
ministered regularly to ensure that reinfection did not occur during (40% tincture of merthiolate, 5% formaldehyde, 1% glycerol) and ex-
the study period. The treatment was personally administered by social amined microscopically. These tests were performed at the beginning
workers of the medical dispensary, and any patient who missed two of the study and at regular intervals during the treatment period. Fe-
successive doses was withdrawn from the study. The year of treatment cal egg counts were not performed on the study group, but in work
was considered as Year 1 of the study, and the subsequent 2 yr, when that is not reported here, we have found that the whole population
the anthelminthic agent was not administered, were designated Years from which the patients were drawn has a point-prevalence of 40 to
2 and 3. Because of the degree of poverty of the patients, the level of 50% for intestinal helminths, and that the intensities of infection are
autoadministration of anthelminthic agents is minimal, and we found from light to moderate. For example, the median egg count per gram
no evidence of this occurring in the control group. of feces in infected individuals was 1,540 for Ascaris lumbricoides.
52 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL. 156 1997

TABLE 1
EFFECT OF ANTHELMINTHIC TREATMENT ON THE CONTROL OF ASTHMA

Control of Asthma*

Maintenance Treatment MDI Crises


Year† (mo) (n/yr) (n/yr)

Treated group, n 5 39 0 5.5 6 0.8 4.5 6 0.7 4.3 6 1.0


1 3.9 6 0.8 2.3 6 0.4 2.9 6 0.8
2 2.4 6 0.7 2.1 6 0.6 1.9 6 0.8
3 5.6 6 0.8 5.3 6 0.9 4.3 6 1.0
Untreated group, n 5 50 0 6.7 6 0.8 4.0 6 0.7 3.8 6 0.9
1 6.6 6 0.8 4.3 6 0.7 3.8 6 0.9
2 7.1 6 0.8 4.8 6 0.7 3.6 6 0.6
3 7.0 6 0.8 5.0 6 0.6 3.6 6 0.5

Definition of abbreviation: MDI 5 metered dose inhaler.


* Mean 6 SEM of number of months per year that maintenance therapy was administered, number of metered dose inhalers consumed
per year, and number of asthmatic episodes per year that required outpatient attention.

Year 0 5 year prior to study. Year 1 5 year of anthelminth administration in the treated group. Years 2 and 3 5 first and second post-
treatment years.

Immunologic Evaluation significant changes were found in these parameters in the un-
Skin-prick tests for immediate hypersensitivity were performed with treated control group. Of the 39 anthelminth-treated patients,
extracts of Dermatophagoides pteronyssinus and A. lumbricoides, and 35 were followed for a further 2 yr (Years 2 and 3), during
as a positive control, with 1% (wt/vol) histamine. Wheal diameters of which time the anthelminth was not administered. Table 1
> 3 mm were considered positive. Total IgE levels were measured shows that the severity of the asthma continued to decline
with the Phadebas radioimmunosorbent test (PRIST) (Pharmacia, during Year 2, but that it reverted to the initial levels in Year
Uppsala, Sweden), and expressed as IU/ml. Levels of IgE for the fore- 3. We should note here that the four patients who were lost to
going allergens were measured with the Phadebas radioallergosorbent
long-term follow-up were not remarkable in the severity of
(RAST) test, and expressed as Phadebas RAST units/ml (PRU/ml).
As suggested by the manufacturers of the test, values > 0.7 PRU/ml
their asthma during Year 1. In Table 2 we present the fre-
(RAST Level 2) were considered positive. quency distribution of asthmatic crises in the 35 anthelminth-
treated patients who were evaluated over the entire 4-yr pe-
Statistical Analysis riod. It can be seen that before the anthelminth treatment
Owing to a high degree of dispersion of the values of most of the contin- (Year 0), the therapeutic regimen used by the asthma clinic re-
uous variables measured, nonparametric statistical tests (one-way anal- sulted in the symptoms being well controlled in 60% of the pa-
ysis of variance [ANOVA], Wilcoxon’s test) were applied, using the In- tients, moderately controlled in 28%, and poorly controlled in
Stat program of Graphpad Software (San Diego, CA). For convenience 12%. For the year following the period of anthelminth admin-
of presentation, the means 6 SEM are shown in the tables. Frequency istration (Year 2), these percentages were 80%, 17%, and 3%,
analyses of discrete variables were performed with the chi-square test. respectively (p , 0.01).
RESULTS Pulmonary Function
Parasitologic Evaluation The pulmonary function of the anthelminth-treated and con-
At the beginning of the study, 41% of the entire group of pa- trol groups was measured immediately prior to the beginning
tients were found to be infected with helminths. The predomi- of the study (Year 0) and at the end of Year 1. The spiromet-
nant parasites were Trichuris trichiura (26%) and Ascaris lum- ric results were expressed as percentages of the predicted val-
bricoides (23%). Infections were detected at some time in six ues, and in Table 3 it can be seen that no significant changes
of the anthelminth-treated patients during Year 1 of the study. were detected in either group. The FEV1/FVC ratios were also
unchanged (mean 6 SD of the treated group: 76 6 8% in
Clinical Status Year 0 and 80 6 10% in Year 1). We should note here that pa-
Owing to the low level of literacy and medical awareness of
the study group, we chose three criteria, that depended di-
rectly or indirectly on the asthma clinic, to estimate the clinical
TABLE 2
status of the patients. These were: (1) the number of months
per year that maintenance therapy with beclomethasone was FREQUENCY OF ASTHMATIC CRISES IN 35
ANTHELMINTH-TREATED PATIENTS
administered; (2) the number of metered-dose inhalers (MDI)
of salbutamol that were used electively by the patients to con- Year*
trol symptoms; and (3) the number of times the patients re- †
No. of crises/yr 0 1 2 3
quired attention in the asthma clinic for episodes that did not
respond adequately to the b2-agonist. The results of this analy- ,3 21‡ 25 28 24
sis are presented in Table 1, where it can be seen that during 3–12 10 8 6 6
. 12 4 2 1 5
the year of anthelminth treatment (Year 1), there were statis-
tically significant decreases in the number of months of main- * Year 0 5 year prior to study. Year 1 5 year of anthelminth administration. Year 2
tenance treatment (p , 0.01), the number of asthmatic crises and 3 5 the first and second posttreatment years.

Number of asthmatic episodes per year that required outpatient attention.
(p , 0.001), and the number of MDIs used (p , 0.001) as com- ‡
Number of patients. Only the 35 patients who were followed for 3 yr are consid-
pared with the year prior to the study (Year 0). In contrast, no ered.
Lynch, Palenque, Hagel, et al.: Helminthic Infection and Asthma 53

TABLE 3 had positive results for both Dermatophagoides and Ascaris


EFFECT OF ANTHELMINTHIC TREATMENT ON (15%).
PULMONARY FUNCTION

% Predicted Values* DISCUSSION


Year FVC FEV1 PEFR MMEF There exists considerable evidence that helminthic infection
Treated group 0 85 6 4 73 6 3 77 6 4 60 6 4
can either increase or decrease the allergic reactivity of in-
1 82 6 3 76 6 4 80 6 4 65 6 4 fected populations (3, 6, 7). First, helminthic parasites can
Untreated group 0 84 6 3 77 6 3 77 6 4 57 6 3 stimulate the production of large amounts of specific IgE anti-
1 85 6 4 74 6 4 75 6 4 63 6 4 body against their own antigens, which sensitizes the mast
* Mean 6 SEM of spirometric values, expressed as percentages of the predicted nor-
cells of the host (1). This, coupled with the fact that many of
mal values. these parasites have lung-migratory phases, and that soluble

Measured immediately prior to the study (Year 0) and at the end of Year 1. parasite antigens circulate in the blood (22), suggests that such
infections could affect pulmonary physiology (6, 7). Helminths
also cause a polyclonal stimulation of IgE synthesis, which at
low intensities of infection results in enhanced allergic reactiv-
tients who at the beginning of the study were positive for hel- ity toward environmental allergens (10–13). In contrast, heavy
minths in the fecal examination showed no significant differ- parasite loads provide such a strong polyclonal stimulus that
ences in spirometric values from those who were negative the excess IgE blocks the allergic response (3, 7, 14). In view
(results not presented). Comparing the BHR to histamine be- of these considerations, the effect of anthelminthic treatment
fore and after anthelminth treatment, the PC20 values were in- on the allergic reactivity of endemic populations will depend,
creased in 38% of the patients, remained unchanged in 44%, at least in part, on the initial intensity of the infection and the
and decreased in 18%. Of particular interest is the observation allergic condition of the subjects. In accord with the complex-
that after treatment five of the patients did not react to hista- ity of this situation is our demonstration in previous studies
mine concentrations as high as 2.5 mg/ml. In fact, these pa- that the anthelminthic treatment of nonallergic children with a
tients became crisis-free, and were able to stop taking mainte- high degree of exposure to these parasites increased their al-
nance beclomethasone for essentially the whole of Years 1 lergic reactivity in immunologic terms (17), but decreased the
and 2. degree of bronchoconstriction associated with the infection
(16). For these reasons we evaluated the effect of sustained
Immunologic Evaluation anthelminthic treatment on the clinical condition of asthmatic
As no clinical changes were found in the control group, total patients in an area in which intestinal helminths are endemic.
and specific IgE levels were measured only in the treated pa- The group that we chose to study belongs to the population of
tients, before (Year 0) and after (Year 1) the period of anthel- an island close to the coast of Venezuela, which has a high
minth administration (Table 4). The total serum levels of IgE, prevalence of asthma (23), and is served by a single medical
which were initially elevated, decreased significantly (p , facility that provides attention and treatment free of charge to
0.001), and significant decreases also occurred in positivity to a community that does not have the financial resources to ob-
Dermatophagoides as reflected both by specific IgE antibody tain these services elsewhere. The prevalence of intestinal hel-
measured by RAST (p , 0.05) and skin-test results (p , minthiasis on the island is about 50%, and is of mild to moder-
0.025). Such decreases did not, however, occur in specific IgE ate intensity. We should note here that although only 41% of
antibody levels or skin-test positivity to Ascaris. In fact, there our patients were found to be infected at the beginning of the
was a tendency toward an increase in these measures. It is rel- study, this does not mean that the rest are not exposed to hel-
evant to point out here that at the beginning of the study pa- minthic parasites, as the human and worm populations in the
tients who were found to be positive for helminths in fecal study area are in dynamic equilibrium situation. In fact, the
testing showed no significant differences in these immune pa- present study found no significant differences in the immuno-
rameters from those who were negative (results not pre- logic parameters investigated in those patients who were posi-
sented). In addition, in the initial evaluations, the spirometric tive and those who were negative for helminths in the initial
results were comparable for patients who had negative skin- fecal examination.
test results for both Dermatophagoides and Ascaris (26% of During the year of regular albendazol administration, the
the group), those who had positive results for Dermatopha- control of asthma in the treated patients was significantly bet-
goides alone (28%) or Ascaris alone (31%), and those who ter than that in both groups the previous year and that in the
control group of untreated patients. This improvement was
even more marked in the year following treatment, but by the
second posttreatment year the clinical condition of the pa-
TABLE 4 tients had deteriorated to its initial level. This accords with re-
EFFECT OF ANTHELMINTHIC TREATMENT ON
sults that we obtained in another study on the island (unpub-
IMMUNOLOGIC PARAMETERS lished data), which showed a relatively low level of reinfection
during the first year after prolonged treatment, but significant
Anti-Dermatophagoides Anti-Ascaris reinfection toward the second year. These results indicate that
(% positive) (% positive)
the beneficial effect of albendazol is related to its anthelmin-
Total IgE* thic activity, and not to a direct effect of the drug on the respi-
Year (IU/ml) RAST† Skin Test‡ RAST Skin Test ratory system. Although we were not permitted to use a pla-
0 2,656 6 256 41 44 44 46 cebo-control in our study, neither the patients nor the medical
1 1,364 6 124 18 18 51 54 staff directly involved in their routine clinical management
were aware of the hypothesis of the study that anthelminth
* Mean 6 SEM IgE concentrations in serum.

Percent of group with specific IgE antibody levels > 0.7 PRU/ml (RAST Level 2). treatment would improve the patients’ asthmatic condition.

Percent of group with immediate wheal diameters > 3 mm. Moreover the criteria used for characterizing the clinical state
54 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL. 156 1997

of the patients were selected for the maximum possible objec- 4. Turner, K. J. 1980. Is the prevalence of allergy related to parasitic dis-
tivity in a study of this nature. Possibly because at the begin- ease? In A. Oehling, editor. Advances in Allergology and Immunol-
ogy. Pergamon Press, Oxford. 279–287.
ning of the study the pulmonary function of the patients, as
5. Grove, D. I. 1982. What is the relationship between asthma and worms?
determined by spirometry, was not profoundly abnormal, the Allergy 37:139–148.
clinical improvement of the treated group was not accompa- 6. Moqbel, R., and D. I. Pritchard. 1990. Parasites and allergy: evidence for
nied by evident changes in measurements of pulmonary func- a “cause and effect” relationship. Clin. Exp. Allergy 20:611–618.
tion. In this respect, other studies have also shown that asth- 7. Lynch, N. R. 1992. Influence of socio-economic level on helminthic in-
matic patients in remission do not necessarily have normal fection and allergic reactivity in tropical countries. In R. Moqbel, edi-
tor. Allergy and Immunity to Helminths: Common Mechanisms or Di-
spirometric values (24). Of possible relevance here is a ten-
vergent Pathways? Taylor & Francis, London. 51–62.
dency that we observed in the treated group toward a lower 8. Finkelman, F., E. Pearce, J. Urban, and A. Sher. 1991. Regulation and
pulmonary sensitivity to histamine challenge, which is an indi- biological function of helminth-induced cytokine responses. Immunol.
cator of BHR. As can occur in viral infection (25), the pres- Today 12:A62–A66.
ence of helminth-derived products, either in the blood or oc- 9. King, C. L., C. C. Low, and T. B. Nutman. 1993. IgE production in hu-
curring during larval migration, may produce inflammation man helminth infection. J. Immunol. 150:1873–1880.
10. Turner, K. J., L. Feddma, and E. H. Quinn. 1979. Non-specific potentia-
and thus increase airway irritability (26, 27). Another factor to
tion of IgE by parasitic infections in man. Int. Arch. Allergy Appl. Im-
be considered is that the tables of predicted values for spiro- munol. 58:232–236.
metric parameters commonly used in Venezuela, which are 11. Joubert, J. R., D. J. Van Schalkwyk, and K. J. Turner. 1980. Ascaris lum-
based on a Spanish sample group (20), may not have been the bricoides and the human immunogenic response: enhanced IgE-medi-
most suitable for our study population. Because “normal” val- ated reactivity to common inhaled allergens. S. Afr. Med. J. 57:409–
ues have not been determined for persons of low socioeco- 412.
12. Lynch, N. R., and M. C. DiPrisco. 1984. High allergic reactivity in a trop-
nomic level in developing countries, where concurrent infec-
ical environment. Clin. Allergy 14:233–240.
tions and nutritional problems could be important variables, 13. Buijs, J., G. Borsboom, J. J. van Gemund, A. Hazebroek, P. A. van Don-
we are unable to make firm statements on this point. gen, F. van Knapen, and H. Neijens. 1994. Toxocara seroprevalence
From the immunologic viewpoint, because the intensity of in 5-year-old elementary schoolchildren: relation with allergic asthma.
helminthic infection in our study population is relatively low, Am. J. Epidemiol. 140:839–847.
we can predict that these parasites would cause both signifi- 14. Godfrey, R. C., and C. F. Gradidge. 1976. Allergic sensitisation of hu-
man lung fragments prevented by saturation of IgE binding sites. Na-
cant increases in total IgE levels and a potentiation of the al-
ture 259:484–486.
lergic response to environmental allergens. The effects of the 15. Lynch, N. R., G. Istúriz, Y. Sánchez, M. Pérez, A. Martínez, and M.
anthelminthic treatment in our study indicated that this is in- Castés. 1992. Bronchial challenge of tropical asthmatics with Ascaris
deed the case, as the total serum IgE levels, which at the be- lumbricoides. J. Invest. Allergol. Clin. Immunol. 2:97–105.
ginning of the study were moderately elevated, decreased sig- 16. Lynch, N. R., I. Hagel, M. Pérez, M. DiPrisco, N. Alvarez, and E. Rojas.
nificantly, as did the allergic reactivity to Dermatophagoides, 1992. Bronchoconstriction in helminthic infection. Int. Arch. Allergy
Immunol. 98:77–79.
one of the predominant allergens in the tropical environment.
17. Lynch, N. R., I. Hagel, M. Pérez, M. DiPrisco, R. López, and N. Alvarez.
Further studies will, however, be required to determine the 1993. Effect of anthelmintic treatment on the allergic reactivity of
degree to which this change contributed to the clinical im- children in a tropical slum. J. Allergy Clin. Immunol. 92:404–411.
provement of the treated patients. Of interest is our observa- 18. DIASPER. 1986. Informe Social 3, Sistema de indicadores sociales para
tion that the specific response to Ascaris, one of the most com- un diagnóstico social permanente. Caracas, CORDIPLAN.
mon intestinal helminths on the island on which our study was 19. American Thoracic Society. 1987. Standardization of spirometry—1987
update. Am. Rev. Respir. Dis. 136:1285–1298.
conducted, was maintained during the year of anthelminth ad-
20. Cobos, N. 1979. Valores de predicción en función pulmonar. Arch.
ministration. This probably occurred because: (1) the patients Bronco. Neumonol. 15:64–70.
received continual immunologic stimuli in the intestine through 21. Cockcroft, D. W., D. N. Killian, J. J. Mellon, and F. E. Hargreave. 1977.
the ingestion of infective eggs; and (2) because the specific re- Bronchial reactivity to inhaled histamine: a method and clinical sur-
sponse to parasite antigens is relatively independent of the vey. Clin. Allergy 7:235–243.
polyclonal stimulus, particularly in persons with an atopic dis- 22. Tanaka, K., H. Kawamura, N. Tohgi, M. Tsuji, Y. Miyachi, and A. Mi-
yoshi. 1983. The measurement of Ascaris suum protein by radioimmu-
position (unpublished observations). In fact, as the IgE response noassay in sera from patients with helminthiasis and with gastrointes-
can participate in protective mechanisms against helminthic tinal disease. Parasitology 86:291–300.
infection (6, 28, 29), it can be proposed that the allergic geno- 23. Istúriz, G. 1987. Etiopatogenia del asma de base inmunológica. Neumos.
type has been conserved in evolution because of the more ef- 5:35–39.
fective antiparasitic IgE response that it confers. 24. Perin, P. V., D. Weldon, and S. J. McGeady. 1994. Respiratory patho-
In conclusion, the results of this study are consistent with physiologic responses: objective indicators of severity of asthma. J. Al-
lergy Clin. Immunol. 94:517–522.
the possibility that helminthic infection can contribute to the 25. Bjornsdottir, U. S., and W. W. Busse. 1992. Respiratory infections and
symptomatology of asthma in an endemic situation, and that asthma. Med. Clin. North Am. 76:895–915.
this could occur both through a direct effect of the parasite 26. Kay, A. B., R. Moqbel, S. R. Durham, A. J. MacDonald, G. M. Walsh,
and through the nonspecific potentiation of allergic reactivity R. J. Shaw, O. Cromwell, and J. A. Mackay. 1985. Leucocyte activa-
toward environmental allergens. tion initiated by IgE dependent mechanisms in relation to helminthic
parasitic disease and clinical models of asthma. Int. Arch. Allergy Im-
munol. 77:69–72.
References 27. Askenase, P. W. 1992. Delayed-type hypersensitivity recruitment of T
1. Jarrett, E. E., and H. R. Miller. 1982. Production and activities of IgE in cell subsets via antigen-specific non-IgE factors or IgE antibodies: rel-
helminth infection. In P. Kallós, editor. Immunity and Concomitant evance to asthma, autoimmunity and immune responses to tumors
Immunity in Infectious Diseases, Vol. 31: Progress in Allergy. Karger, and parasites. Chem. Immunol. 54:166–211.
Basel. 178–233. 28. Hagel, I., N. R. Lynch, M. C. DiPrisco, E. Rojas, M. Pérez, and N. Alva-
2. Lynch, N. R. 1987. Immediate hypersensitivity (allergic) reactions to in- rez. 1993. Ascaris reinfection of slum children: relation with the IgE
testinal helminthic infections. Baillières Clin. Trop. Med. Commun. response. Clin. Exp. Immunol. 94:80–83.
Dis. 2:573–593. 29. Capron, A., J. P. Dessaint, and M. Capron. 1992. Allergy and immune
3. Hagel, I., N. R. Lynch, M. C. DiPrisco, R. López, and N. García. 1993. defence: common IgE-dependent mechanisms or divergent pathways.
Allergic reactivity of children of different socioeconomic levels in In R. Moqbel, editor. Allergy and Immunity to Helminths: Common
tropical populations. Int. Arch. Allergy Immunol. 101:209–214. Mechanisms or Divergent Pathways? Taylor & Francis, London. 1–16.