Diagnostic tests in ragweed-allergic

asthma A comparison of direct skin tests, leukocyte histamine release, and

quantitative bronchial challenge

C. Allen Bruce, M.D., Richard R. Rosenthal, M.D.,

Lawrence M. Lichtenstein, M.D.,* and Philip S. Norman, M.D.

l3a1timore xa.

Thirty-six patients with a hi&n-y of secmmd ragweed asthma were tested. Direct intradermal skin tests, leukooyte histamine release, and quantitative i&u&ion bronchial challenge correlated significantly. Data reported suggest that quantitative skin tests are as cltignostioally valuable as qwLntitatiae inha&ttion bron&Gl &al- lenge or leukocyte histomiw release. Data also suggest that lzlng and skin mast oells and droulating basophils respond as a single population of cells to ragweed antigens.

The use of inhalation bronchial challenge with various antigens for the diagnosis of allergic asthma is reported by many investigators to be more reliable than direct skin testing in ascertaining clinically significant disease.lU1’ Many reports have shown a poor correlation between skin testing and bronchial challenge.lg 12-23 Colldahl and otherPa” have, however, found some association between positive provocation tests in patients or subhuman primates and the degree of skin sensitivity.

h possible basis for the difference between the sensitivity of lung and skin was suggested by work with ascaris-sensitive primates. Patterson, Talbot and 12randf’onbrener”’ have postulated the existence of’ more than one population of mast cells to explain the dissociation of inhibition by &sodium cromoglycate of cutaneous and respiratory sensitivity to c:hallenge with ascaris antigen. Assem and MongarCS2 have also reported the failure of disodium eromoglycate to inhibit direct skin tests, I’rausnitz-Kiistner reactions, or leukocyte histamine release while significantly inhibiting histamine release from passively sensitized chopped human ant1 monkey lung.

From the Clinical Jmmunology Division, The Johns Hopkins University School of ?vIedicine at, The Good Samaritan Hospital.

Supported by Research Grants AI 04866, AT 08270, and Al 10304 and Training Grant. Al 00423 from the National Institute of Allergy and Infectious Diseases of the National Institutes of Health, Bethesda, Md. PuMication No. 101 of the O’Neill Research Laboratories.

Received for publication Aug. 23, 1973.

Reprint requests to: C. Allen Bruce, XI)., The Good Samaritan Hospital, 5601 Loch Raven Blvd., Baltimore, Md. 21239.

‘Recipient of Research Career Development Award AI 42373 from the National Institute of Allergy and infectious Diseases of the National Institutes of Health, Bethesda, ?ild.

VOLUME 53 NUMBER 4

Tests in ragweed-allergic asthma 231

We have recently shown a significant correlation between serum IgE, direct skin tests (mast cells), and leukocyte histamine release (basophils) in ragweed hav fever patients.33 All three measurements correlated well with symptoms dur- Y ing the ragweed hay fever season. 34 These data suggest that populations of mast cells in the nose and skin and the basophils of blood are similar, or at least are in equilibrium with the same pool of IgE, with all cells responding similarly to ragweed pollen exposure.

The purposes of the present investigation are twofold: (1) to examine the

relationship between direct skin tests, leukocyte histamine release, and quantita- tive bronchial challenge in ragweed-allergic asthmatic patients and (2) to assess the relative value of these tests in a group of patients with a clinical history of asthma in the ragweed season.

MATERIALS AND METHODS

Screening questionnaires were sent to 278 patients responding to newspaper announce-

ments about studies of immunotherapy and asthma. Of those returning the questionnaires, 66 indicated a history of asthma in the ragweed season and were evaluated by a physician in

the clinic. After a history and physical examination, patients were skin tested on the volar aspect of the forearms to crude ragweed pollen extract (Center lyophilized Lot No. 16608FD

assayed to contain 26.67 cg antigen E per milliliter, 10,000 PNU per milliliter, 100 pg

protein nitrogen per milliliter, or l/100 W./V.), antigen E,* Ra3,” Ra5,” and control. Antigens

were diluted in tris buffer containing 0.03 per cent serum albumin as a stabilizer. The skin testing technique has been described more fully elsewheress; 0.05 cc. of solution was injected

and the reaction read at 15 minutes. Patients having positive skin tests to crude ragweed at 1 x 10-c ,ug of protein nitrogen per milliliter were tested with serial dilutions until the con-

centration required for a threshold 2+ reaction was determined. A 2+ reaction was defined as 10 mm. of wheal and 20 to 30 mm. of erythema measured in two dimensions. All tests were performed before the season of ragweed pollination.

Thirty-six patients, 20 females and 16 males, aged 18 to 5’5, were selected on the basis

of symptoms of asthma in the ragweed season, but not perennial asthma, no immunotherapy in the previous 2 years, and a positive skin test to ragweed, for further studies. Thirty-four

of the 36 patients selected in addition gave a history of hay fever corresponding to the

ragweed season. The thirty remaining patients were rejected for various reasons. Three failed to return for further tests. Twenty were rejected because their history taken in the

clinic did not coincide with the ragweed pollination season. Seven had a seasonal history of

asthma correlating with the ragweed pollination season; of these 6 had negative skin tests to ragweed extract at 1 pg per milliliter; 1 had a positive skin test only at 1 pg per milliliter.

Four of these 7 patients had bronchial challenge performed.

The 36 patients returned to the clinic on a separate day for leukocyte histamine release and quantitative bronchial challenge. The patients were instructed not to take any medications

for 24 hours before the tests. Leukocyte histamine release was performed with ragweed antigen E by May’s modification of the technique described by Lichtenstein and Osler,s% 3s as has been

reported in detail previously. Dose-response curves were constructed from which the concentra-

tion of antigen E producing 56 per cent histamine release was interpolated. For those pa- tients not releasing 50 per cent of their histamine, the maximal percentage of histamine re-

leased to antigen E was used in further comparisons. Bronchial challenge tests were performed as described by Rosenthal and Norman37 using

a variable pressure body plethysmograph to determine specific airway conductance (SoAW)

according to the method described by Dubois, Botelho, and Comroe.ss After a baseline Se,,

was determined, patients inhaled first 5 and then 40 breaths of nonphenolated saline. Deter-

*Courtesy of Drs. D. Marsh, L. Goodfriend, and T. P. King.

232 Bruce et al. J. ALLERGY CLIN. IMMUNOL. APRIL 1974

TABLE I

Patient Age

2+ skin test* I

crude ragweed

Ug protein 2+ skin test* 50 % histaminet release, Sex nitrogen/ml.) Ag E @g/ml.1 Ag E @g/mf.I PDs,S w.i

C. B. &I-. F. c. D. c. K. 1~. J.

k. ii. s. s. J. M. I). II. R. Ii. B. L. H. w. I!-. F. s. u.

i p”. i. ii. MCI. R. A. 8. 5. 1-I. 7

,“*k H: ‘H:

p”: I”;. J. 8. J. 13. w. M.

FH” S: G: T. 8. M. B.

46 30 52 34 22 33 18 30 30 22 25 33 22 40 33 37 21 33 18 35 23 25

;i

ii 25

2 43 29 55 28 "9 20 51

1 x IO--G 1 * LO -6

1 x 10-S 2.5 x 10-s I x 10-T Sot done 1 X 10-Z 4 x 10-S 3 x 10 3 1.4 x 10-d

0.06 0.095 0.14 0.62

1 x 10-t; 1 x 10-a

1.05 1.08

3 x 10--s Not done 1 x lo-’ :j % 10-d 2.5 x 10-s 6.5 x 10-s 1.5 X lo-’ 5 x lo-’ 1.5 x 10-a 1 x 10-J

15% max. at I x 10-L’ 1.8 X 10-s 2 x 10--j 2.7 x 10-e 3.9 x 10-h 3.3 x 10-s 1.8 % 10-J

1.40 1 x 10-S 1 x 10--a

1.45 1.60

1 x 10-S 3 x 10 3 1 x 10-r 1 x 10-S 1 x 10-t; 3 x 10-3 1 x 10-I 1 x 10-s

1.75 1 x 10-e 3 x IO-.$

2.00 2.42

1 x 10-Z 3.50 1 x 10-J 3 x 1 0 3

3.60 5.00

1 x IO-1 5.20

5.50 5.80 8.50

1 x 10-S 1 X 10-b 1 X 10-Z

1 X 10-s 1 X 10-r 1 X 10 5 1 X 10-h

3 x 10-h 1 x 10-4 1 x IO-5

9.40 10.0 11.0 16.0 21.0 24.5 25.0

1 x 10-4 1 x 10-a 1 x 10-d 1 x 10-d 5 x 10-Z 3 x 10-a 1 x 10-k

3 x 10-s 4.2 x 10-s 6.5 x 10-l 1 x 10-s

1 x 10-k 1 x10-4 3 x 10-3 1.5 x 10-S

2.6 x 10-5 1 x 10-a 1 X 10-d

Seg. at 10-l 3 x 10 5

29.0 82.0 2 x 10-4

3 x 10-r 1 X 10, 1 x 10-J 1 x lo-:%

Seg. at 10-r 42% max. at 5 x 10-Z

105.47 130.0 150.0 3 x 10 4

1 X 10 ” I x 30-S 1 x 10 ’

Seg. at I x 10-r 4% max. at 1 x 10 1

6 x lo-:+ Neg. at 1 x 10-l > Not done

17% max. at 1 x 10-l

550.0 770.0

1,000 1,000 1,000

Seg. at 10 * 1. x 1 o- 3

“0.05 C.C. injected; 2+ reaction = 10 mm. wheal and 20-30 mm. erythema measured in two dimensions at 15 minutes.

t:For patients not releasing 50% histamine, the maximum % released is reported. $Provocation dose of ragweed causing 3570 decrease in S ei\,+. expressed in units, with one

unit defined as one breath of one fig protein nitrogen per milliliter of rngweed extract.

minations of S,,, were carried out immediately and 10 minutes after each set of inhalations.

s U*W 10 minutes after 40 breaths of saline was called 100 per cent of control t.o eliminate

nonspecific effects of saline from further determinations. Subsequent determinations of SCh,v

done 10 minutes after antigen challenge were expressed as a percent,age change from diluent control. So patients had bronchospasm prior to bronchial challenge. Two, 5, 10, 20, and 40

breaths were taken from a compressed air-powered dosimeter delivering 0.022 C.C. of antigen solution per breath. Dosage of inhaled antigen was expressed in units with one unit defined

as one breath of 1 cg protein nitrogen per milliliter (100 PN\Tu per milliliter, l/IO,000 W./V.) ; therefore, 40 breaths of 10 cg protein nitrogen per milliliter = 400 units. The challenge

sequence was begun with 2 breaths of a fresh 1 x 10--z ,kg per milliliter dilution (1 PNU per milliliter, 1/1,000,000 W./V.) of crude ragweed extract. Challenge was continued with increasing strength solutions until a 40 per cent drop in 3 ?(DAW was obtained or 40 breaths of

VOLUME 53 NUMBER 4

Tests in ragweed-allergic asthma 233

I00 -

F 3

i :: 10-1 - .

E

2 .

w

6 2 10-2 - . I Unit :I Breathof lyg of Prot N/ml

of Ragweed Extract 0 ti I= 064

3 p < 001 2 10-3 - a

IO0 IO'

PC&(UNITS i

Fig. 1. Provocation dose of crude ragweed extract causing 35 per cent decrease in airway conductance expressed in units [abscissa] vs. 2+ skin test response to crude

ragweed pollen extract expressed in pg protein nitrogen per milliliter (ordinate) in 36 patients with a history of asthma during the ragweed season.

10 ,,~g per milliliter (1,000 PNU per milliliter, l/1,000 W./V.) was inhaled without a drop in

airway conductance. A dose-response curve was drawn plotting cumulative dose of antigen inhaled against percentage of control SolW. The provocation dose causing a 35 per cent

drop in airway conductance was determined and designated the PD,,.

RESULTS

All data obtained in this study are provided in Table I, which lists the con- centration of antigen E and crude ragweed extract required for a 2+ skin test, the cumulative dose of ragweed extract which produced a PD,, and the con- centration of antigen E required for 50 per cent histamine release. The con- centration of antigen required for a 2+ skin reaction ranged from 1 x 1&G pg protein nitrogen per milliliter to 0.5 pg protein nitrogen per milliliter. To achieve 50 per cent leukocyte histamine release required from about 1O-G to 1O-2 pg of antigen E per milliliter. In some patients whose cells did not release histamine or released less than 50 per cent of the cellular histamine, the antigen E concentration employed was up to 1 pg per milliliter. The concentration of ragweed extract that on bronchoprovocation gave a PD,, was from 6 x 10m2 U. to greater than 1,000 U. The precision of these measurements varies widely, from t 10 per cent for histamine release to f threefold and t tenfold for the

234 Bruce et al. J. ALLERGY CLIN. IMMUNOL.

APRIL 1974

!

-------I A 50% h!slomlne release to

Crude Rogweed but not 10 / Antigen E

B ?otlents releosmq less thon ’ 50 % hlstomme

0 50% hlstomlne release to / Antigen E

--

l Untt 1 I Breath of ipg of Prot N /ml

of Ragweed Extract

4 9:

.

.

P< 001 .

. . . . . . .

. . . l

’ .

. l e . . .8 l

F I),,, ‘(J’, icy

FIG. 2. Provocation dose of crude ragweed extract causing 35 per cent decrease in

airway conductance (abscissa) vs. leukocyte histamine release to antigen E (ordinate) in

33 patients with a history of asthma during the ragweed season.

TABLE II. Control patients: Seasonal asthma with symptoms corresponding to ragweed

season by history

SO% 2+ skin test histamine

2+ skin tart crude ragweed* /

Ag E* release, Ag E Patient Age Sex Wg/ml.) l&g/ml.) PO,, (U.)t

E.M. 21 hf. Neg. at 1 pg Neg. Not done Neg. at 1,000 C. LX. E. 44 M. 2+ at 1 pg Neg. Not done Keg. at 1,000 U.

21 v”:zi-* 19

F. Neg. at 1 pg Neg. Xot done Neg. at 1,000 I:. F . Seg. at 1 pg Seg. Not done Neg. at 1,000 U.

*0.05 G.C. injected; 2+ reaction = 10 mm. wheal and 20-30 mm. erythema measured in two dimensions at 15 minutes.

tProvocation dose of ragweed causing 35% decrease in S oAW expressed in units with one unit defined as one breath of one pg protein nitrogen per mil~ilitcr of ragweed extract.

skin testing and bronchoprovocation assays, respectively.33, 57 Table II shows results of these tests in four seasonal asthmatics who were not ragweed-sensitive by skin test.

The relationships between these different measures of sensitivity are shown in Figs. 1 to 4. In Fig. 1 the concentration of crude ragweed extract giving a 2.1. skin test is plotted against that required for a PI),,. By nonlinear regression analysis, the correlation coefficient, r, is 0.64 with p < 0.001.

Fig. 2 presents a plot of the concentration of antigen E which causes 50 per cent histamine release from leukocytes versus PI),,. By nonlinear regression

VOLUME 53 NUMBER 4

Tests in ragweed-allergic asthma 235

l A

.

.

l

. .

. .

Potlent releoslng less than

50% hasiomlne

0 Patlent releoslng 50 %

A 50% hlstomlne releose to

Crude Ragweed but not

r= 0.69

P<DOI Id6 t I I I I I 1

lO-6 lO-5 lo-4 lo-3 lO-2 IO-’ I bJ9

CRUDE RAGW,EED,pg/ml 2t SKIN TEST

FIG. 3. 2+ skin test response to crude ragweed pollen extract (abscissa) vs. leukocyte

histamine release to antigen E (ordinate) in 34 patients with a history of asthma during the ragweed season.

analysis, r = 0.69 with p < 0.001. The 7 patients releasing less than 50 per cent of their histamine to 1 x 10-l pg antigen E are plotted with a square symbol. Six were in the least sensitive group by bronchial challenge: By t test analysis these “low histamine releasers” were significantly less sensitive than the “good” releasers to bronchial challenge with antigen (p < 0.001).

Fig. 3 shows the correlation between the concentration of crude ragweed extract required for a 2+- skin test response and the concentration of antigen E necessary for 50 per cent histamine release. By nonlinear regression analysis; r = 0.69 with p < 0.001. Less than 50 per cent histamine release to antigen E was obtained in 7 patients. One of the 7 released 50 per cent of his histamine to crude ragweed and Ra3 but not to antigen E.

Fig. 4 shows the correlation of the 2+ threshold skin test to antigen E and the concentration of antigen E required for 50 per cent histamine release. By nonlinear regression analysis, r = 0.81 with p < 0.001. In both instances, as we have shown previously, the patients who release less than 50 per cent of their leukocyte histamine on challenge with antigen E are significantly less sensitive on skin testing with antigen E or crude ragweed extract (p < 0.001).

DISCUSSION

A number of investigators have reported data dealing with the relative value of various tests in the diagnosis of allergic asthma. Several recent reports have shown an association between a “positive” radioallergosorbent test and a

236 Bruce et al. J. ALLERGY CLIN. IMMUNOL. APRIL 1974

.

. . .

0’

10-4

IO5

. 0

1 . .

. .

.

. . 3 .

r= 0.8

p<.OOl

. 50 % H~siammeReleose

l Less than 50 % I Ylstamme Release

to-6 I I I I I I 10 6 6 IO-" IO ' !O i K-1

2r SKIN TEST TG ANTIGEfv E (,lg/v’;

FIG. 4. 2+ skin test response to antigen E (abscissa) vs. leukocyte histamine release to

antigen E (ordinate) in 34 patients with a history of asthma during the ragweed season.

clinical history of sensitivity to certain allergens, a positive skin test, and posi- tive provocation tests. w **I ao Other reports have shown a positive correlation between increased bronchial tolerance and decreased asthma symptoms after treatment with various allergcns,40-4* but one report indicated increased bronchial tolerance with immunotherapy, but no decrease in symptoms.4” Some investigators feel that a positive bronchial challenge test correlates better with clinical history than with skin tests. 7l M Holman, Molk, and Micklich4F reported a 70.9 per cent and 93.9 per cent correlation, respectively, between skin tests and bronchial challenge with dust and mold extracts, and a 60 per cent correla- tion with ragweed and grass pollen extracts. It is important to note that these papers deal only with data as positive or negative and symptoms as present, or absent. None of them are quantitatiw in the sense that they examine whether the sensitivity of one test correlates with the sensitivity of another or with t,he severity of clinical di.sease. Studies reporting a poor correlation between skin tests and bronchial challenge may be due to patient selection, the failure to perform serial dilutions of skin tests, or the use of less sensitive methods for bronchial challenge.

The finding that results from skin tests, histamine release, and bronchial challenge correlate in a quantitative fashion raises some questions about accord- ing bronchial challenge a special place in the diagnosis of allergic asthma. We are dealing here with a single allergen and mostly with highly allergic and

VOLUME 53 NUMBER 4

Tests in ragweed-allergic asthma 237

asthmatic patients; the few asthmatic but skin-test negative patients we have studied had negative responses to challenges. More investigation of ragweed- allergic but not asthmatic patients will help to assign a proper place to the chal- lenge technique as an adjunct to diagnosis.

The quantitative aspects of challenge deserve to be emphasized; presumably individuals whose PD,, is only a few units should have a greater chance of responding with asthma during seasonal exposure to pollen. When these patients keep symptom diaries during natural exposure, it. will be possible to examine the correlation between symptomatology and various diagnostic tests. However, the data reported here suggest that for the diagnosis of seasonal asthma, quanti- tative skin tests or leukocyte histamine release are as diagnostically valuable as bronchial challenge. The quality of the extract employed may be important in this regard. We used a lyophilized extract ric,h in antigen E, and skin test dilu- tions were made in a buffer containing human serum albumin as a stabilizer.

The report by Patterson, Talbot, and BrandfonbreneF suggesting different populations of mast cells based on response to disodium cromoglycate may be reinterpreted to indicate tissue specificity for the inhibitory effect of disodium cromoglycate rather than the existence of two populations of mast cells. Assem and Monga@ achieved significant inhibition of histamine release from sensitized chopped lung by disodium cromoglycate, but only when antigen was not present in too great excess; there was, moreover, no dose-response relationship observed in the inhibition. They also found that direct skin tests and Prausnitz-Kiistner reactions were not inhibited by disodium cromoglycate. These findings are in accord with Patterson’s data, but it should be noted that Assem and Mongar used antigen concentrations producing large skin test responses by prick test and did not attempt to inhibit ‘L+ threshold intradermal skin test responses. We and others have failed to obtain inhibition of antigen-induced leukocyte histamine release by disodium cromoglycate. =, 48 Our data suggest that the response of lung and skin mast cells and circulating basophils to ragweed antigens occur as if they were a single population of cells in equilibrium with

the pool of IgE anti-ragweed antibody.

REFERENCES

1 Stevens, F. -1.: -1 comparison J. ALLERGY 5: 285, 19’34.

2 Lowell, F. C., and Schiller, I,

of pulmonary and dermal sensitivity to inhaled substances,

W.: The induction of asthmalike attacks in subjects with “idiopathic” asthma, J. ALLERGY 19: 172, 1948.

3 Arner, B.: Provocation tests through inhalation of allergen extracts, Experiments with objective registration of the discomfort Acta Med. Stand. (Suppl.) 239: 327, 1950.

4 Juhlin-Dannfelt, C.: On the significance of exposure and provocation tests in allergic diagnostics, Acta Med. Seand. (Sup@.) 239: 320, 1950.

5 Colldahl, H. : A study of provocation tests on patients with bronchial asthma, Aeta Allergol. 5: 133, 1952.

6 Engstram, I., Karlberg, P., Koch, G., and Kraepelien, 8.: Use of analysis in mechanics of breathing in provocation test in bronchial asthma, Acta Paediatr. &and. 47: 441, 1958.

7 McAllen, M. K.: Bronchial sensitivity test,ing in asthma, Thorax 16: 30, 1961. 8 Itkin, I. H., Anand, S., Yau, M., and Middlebrook, G.: Quantitative inhalation challenge

in allergic asthma, J. ALLERGY 34: 97, 1963. 9 Bernstein, I. L., Kreindler, A., and Sugeman, D.: Direct bronchial testing in allergy,

Ann. Allergy 22: 49, 1964.

238 Bruce et al. J. ALLERGY CtIN. IMMUNOL. APRIL 1974

11

12

13

14

15

16

17

18

19

20

10 Colldahl, H., Holmgren, A., Pegelow, K. O., and Svanborg, S.: Variations of airlvny resistance in provonation tests on asthmatic- patients, measured with dif’ferent n~~~thod~, Bets Allergol. 19: 325, 1964. Olive, J. T., and Hyatt, X. E.: Maximal expiratory flow and total respiratory rcsistanctb during induced bronchoconstriction in asthmatic subjects, Am. Rev. Resp. His. 106: 3fifi:

197” . I.

Harris, T.. IT.: Experimental reproduction of respiratory mold allergy, .I. ~~tLE:KGY 12: “79, 1941. Schiller, 1. W., and Lowell, F. C. : The inhalation test as a diagnostic proce~lurc wiiil special emphasis on the house dust allergen, J. ALLERGY 23: 234, 1952. Citron, R. M., Frankland, A. W., and Sinclair, J. 11. : Inhalation tests of bronc~hial hyper- sensitivity in pollen asthmn, Thorax 13: 229, lP58. Fagerberg, E. : The prevalence of dust allergy in lnonchial asthma sud the importance of carrying out provocation tests even when skin tests reveal negative results, A& hllergol. 16: 449, 1960. Kaude, J.: Inhalation and skin tests in asthmatic children, Helv. Paediatr. Acta 6: 580, 1960. Bruce R. A. : 22: 264, 1963.

Bronchial and skin sensitivity in asthma, Int. Arch. Allergy Appl. lmmuno!.

Melon, 1’. J., Marcelle, R., Petit, .J. M., and Lecomte, J.: Correlation entre les tests cutanes et les tests de provocation bronchique ches l’asthmatique, Int. Arch. Allergy Appl. Immunol. 25: 271, lW4. Colldahl, H.: The importance of inhalation tests in the etiological diagnosis of allergic diseases of the bronchi and in the evaluation of the effects of specific hyposensitization treatment, Acta Allergol. (Suppl.) 8: 7, 1907. Rerg, T., Rennich, H., and Johansson, S. G. 0.: In vitro diagnosis of atopic allergy. 1. A comparison between provocation tests and the radioallergosorbent test,, Tnt. Arch. Allergy Appl. Immunol. 40: 770, 1971. Tse, K. S.: The relationship between skin sensitivity, reagin titer and bronchial sensi- tivity in inhalation challenge test, J. ALLERGY 49: 130, 1972. (Abst.) Radermecker, M., Geubelle, F., and Salmon, J.: lnhalation t&s in monkeys passively sensitized with human serum, Clin. Allergy 2: 247, 1972. Houri, M., Mayer, A. L. It., Houghton, L. E., and Jacobs, I).: Correlation of skin, nawl and inhalation t,ests with the 1gE in the serum, nasal fluid and sputum, Clin. Allergy 2: 285, 1972. Colldahl, H. : A study of provocation tests on patients with bronchinl asthma, Act:: Allergol. 5: 143, 1952. Citron, K. ,M.: The uses of bronchial sensitivity tests, Acta Allergol. (Suppl.~ 8: 17, 1967. Popx, V., Teculescu, I)., Stanescu, D., and Gavrilescu, X.: The value of inhalation tests in perennial bronchial asthma, J. ATLERGY 42: 130, 1968. Hronsky, E. A., and Ellis, 15. F.: Inhalation bronchial challenge testing in asthmatic children, Pediatr. Clin. North Am. 16: 85, lP69. Fagrrberg, E:., and Wide, L.: Diagnosis of hypersensitivity lo dog cpithelium in patients with asthma bronchiale, Int. Arch. Allergy Appl. Tmmunol. 39: 301, 1970. I’att,erson, R., Talbot, C. H., and Hooth, R. H. : Immunoglobulin E-mediated respirator>- responses of subhuman primates, Am. Rev. Resp. His. 102: 412, 3970. Spector, 8. L., and Farr, X. S.: Inhalation challenge in asthmatic~s, d. :\I,T.TW;Y 51: ST, 1973. (Abst.) T’atterson, R.., T,albot, C. H., and Hrandfonbrener, M. : The USC of JgE mndiatc,d respons<“: as a pharniacologic test system. The effect of disodium cromoglycate in respiratory and cutaneous reactions and on the electrocardiograms of Rhesus monkeys, Int. Arch. Allcrg~ Appl. Immunol. 41: 592, 1971. Assam. E. R. K.. and Monear. J. L.: Inhibition of allergic reactions in man and other

21

22

23

24

25 26

27

28

29

30

31

32

33

34

35

species by cromoglycate, IntrArch. Allergy Appl. lmmunol. 38: 68, 1970. Sorman, I’. S., Lichtmstein I,. M., and Ishizaka, K.: Diagnostic tests in ragweed hay fcvcr. A comparison of direct skin tests, TgE antibody measuremrnt,s, and basophil hista mine release, J. ALLERGY 52: 210, 1973. Lichtenstein, I,. M., Tshizaka, K., Sorman, 1’. S., Sobotka, A. R., and Hill, 1%. M.: lgl;: antibody measurements in ragmtyd hay fever. Relationship to clinical scaverity and the results of immunotherapy, J. Clin. Jnvest. 52: 472, 1973. Liehtenstein, 1,. M., and O&r, A. G.: Studies on the mechanisms of hypersensitivity

VOLUME 53 NUMBER 4

Tests in ragweed-allergic asthma 239

36

37

38

39

40

41

42

43 44

45

46

47

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phenomena. IX. Histamine release from human leukocytes by ragweed pollen antigen, J. Exp. Med. 120: 507, 1964. May, C. D., Lyman, M., Alberta, R., and Cheng, J.: Procedures for immunochemical study of histamine release from leukocytes with small volume of blood, J. ALLERGY 46: 12, 1970. Rosenthal, R. R., and Norman, P. S.: Priming phenomenon in the lung, J. ALLERGY 51: 95, 1973. (Abat.) Dubois, A. B., Botelho, 5. Y., and Comroe, J. H.: A new method for measuring airway resistance in man using a body plethyamograph: Values in normal subjects and in patients with respiratory disease, J. Clin. Invest. 35: 327, 1956. Steniua, B., and Wide, L.: Reaginic antibody (IgE), skin, and provocation tests to Dermatophagoides culinae and house dust in respiratory allergy, Lancet 2: 455, 1969. McAllen, M. K., Heaf, P. J. D., and McInroy, P.: Depot grass-pollen injections in asthma: Effect of repeated treatment on clinical response and measured bronchial sensi- tivity, Br. Med. J. 1: 22, 1967. McAllen, M. K., Heaf, P. J. D., and MeInroy, P.: The effect of depot grass pollen injec- tions on bronchial sensitivity in asthmatics, Acta Allergol. (Suppl.) 8: 43, 1967. Pegelow, K. O., Colldahl, H., Ripe, E., Svanborg, N., Sundberg, B., and Werner, M.: Bronchial sensitivity before and during specific hyposensitization, Acta Allergol. (Suppl.,~ 8: 47, 1967. Aas, K.: Bronchial provocation tests in asthma, Arch. Dis. Child. 45: 221, 1970. Aas, K.: Hyposenaitization in house dust allergy asthma, Acta Paediatr. Stand. 60: 264, 1971. Tuchinda, M., and Chai, H.: Effect of immunotherapy in chronic asthmatic children, J. ALLERGY 51: 131,1973. Gayrard, P., Orehek, J., Boutin, C., and Charpin, J.: Valeur du test de provocation par allergenes inhales dans L’asthme, Acta Allergol. 27: 87, 1972. Holman, J. G., Molk, L., and Micklich, D.: Bronchial challenge and akin test correlations, Ann. Allergy 30: 250, 1972. Lichtenatein, L. M., and Adkinson, N. F. : Chlorphenesin : A new inhibitor of IgE-mediated histamine release, J. Immunol. 103: 866, 1969.

Select the ONE best answer for the following question from the Allergy Foundation of America Self-Assessment Program:

Question 2. The most specific skin test for tuberculous infection is the

(A) tine test (B) intradermal test (Mantoux)

(C) sterneedle test (D) patch test (Vollmer)

(E) scratch test (von Pirquet)

The correct answer and bibliographic reference will be found on page 244 of this Journal.