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    Imunoterapie alergie tantari

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    13 views7 pages

    Articol Studiu Alergie Tantari Imunoterapie

    Uploaded by

    sildia009
    Imunoterapie alergie tantari

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    © All Rights Reserved
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    EFFICACY AND SAFETY OF SPECIFIC IMMUNOTHERAPY TO MOSQUITO BITES R. Ariano (1), R.-C. Panzani (2) Summary HE Background: Adverse effects of mosquito bites are ofen very unpleasant and need a treament I Objective: fo elite te ecoy of specie inmunoherepy [wih an exe! of fhe whole body of he mosauio Aedes communis. e HE Method Twenty patients having srong local immedicte ond delayed reactions with in many cases also on llergte thi ee eee eA eater erated git pies Incl sin less potienig skin ka RAST: Gnd aval provcaiion tail Rea AP Tater eel ch, Aodad coramuniniend a batleryrol ihe:commonediiRargees i'sur cioalinchding vo insect: Blatella gormanica {german cockrcuch) and Goslerophiy intestinalis (horse hy) ‘The specific immunotherapy was carried out by the conventionnal subculaneous route. Hl Results: Afer 18 months of ST ll he paiensreporied he dsoppearance of local rections and symploms of allergic thins, which wos corelated witha stlsically mproverent of symplom and drag consumption scores and a decrease of Gllergenicreedfaly by the nasal provocation fe Hl Conclusions: SIT vih on exact of Aedes communis produced afer 18 monhs of treatment a sigifcont improvement of allergic sympioms, a decrease of symptom and drug consumption scores and of allergen specific nasal reactiviy. S.17 in mosquito bite aller ‘appears to be effective and safe in the treatment of both cutaneous and respiratory sympioms. Key-words: Aedes communis - Mosquito bite allergy - Specific immunotherapy. INTRODUCTION expiratory allergy to arthropods is « known but underestimated phenomenon despite the. pio: neering works of Parlato, (1) Perlman (2), Benaiim Pinto (3) and ourselves (4,5,6,7). On the other hand, allergy to stinging insects have been extensively studied as far as Hymenoptera are concerned with, as a correlate, a precise protocol of specific immunothe- rapy (51.1). Allergy to other stinging insects, such as flea, black fly, ants and mosquitoes is also known but fete acterendlliauat Vtensifzalion to mosquito bites is more frequent than allergy to Hymenoptera, Sil has not been uflized very offen. Mosquitoes Culicidae have been the most investigated species, specially in Northern countries of Europe (Finland) with T. Palosuo and T. Reunala, (8-11) and of America and Canada with Peng and Simmons (12). Itis also known that mosquitoes can act as aero allergens as demonstrated in India by Agarwal (13) Mosquitoes are insects which belong to the Diptera order and to the Culicidee family among which we TU aiMadicne Geneiala- Modo d Allergologio ed Inmunolgia Clinica AS. 1 Inprise-Ospodele"S Chorlos®Bordighe (tly) [Fl Conre de Recherche en Allrgaogie 2, rue Edouard Delonglods 12006 Mossel Fence). have three important species: Anopheles, Aedes, Culex. The culicidae family contains more than 2000 species. In Europe, the commonest species are Aedes and Culex but it is possible, in some areas, to find Anopheles, Culiseta and Mansonia (table 1). Culex species generally reproduce in pits, containers, drums of gardens and aquatic environments with organic materials (septic tanks, drainages) Mosquitoes reproduce particularly during the summer season. When they become adult in winter they take refuge in protected places: humid drains, wine cellars, heated rooms. In our area, the most diffuse ond ‘annoying species in houses is Culex pipiens; itis acti- ve all night long, A second prevalent species in Italy is ‘Aedes albopictus, common in Japan, imported a few years ago from the U.S.A and predominant in the countryside ‘The first evidences that the bite reactions are immuno- logical in nature were reported by Mellanby (14) in 1946 and McKiel (15) in 1959. Valentine (16) has firmly established the role of saliva venom showing the sensitization to mosquitoes, When their saliva ducts were cut, they did not elicit cutaneaous reactions in sensitized subjects. Later, the allergens of mosquitoes were characterized and specific IgE and IgG antibo- dies mosiy from the IgG4 subclass were measured by RAST and immunoblotting (17, 18). The main A. com- ‘munis saliva antigens were 22, 30 and 36 kDa which is the most important. REACTIONS Bios induce a variety of immunologic skin reactions The reactions following c mosquito bite are brody of two typeszan IgE medioted wheal and Fare appearing coffer 15 minules and a more or less lasing papular inflation afer in generel 24 hours, However Norge local reactions" ure the commonest. It is an ‘erythema- teous ching local sweling of 3 fo 12 ems occuring wihin 12 hours offer the bite and persisting one o- several days; it seems to be a type | late phase reaction Iki the reaction we generally ound in our patents. This type of reaction occurs frequently when aduls and mostly children are skin tested with « mosquito extract. Sometimes as reported by Frazier (19) there are less easily definable symploms such as joint swelling, nav. sec, headache, dizziness and lethargy. Other symp- toms have been described: Skeeter syndrome is a large local inflammation accompagned with fever, and even respiratory reaction such as asthma (20). Bullous eruptions [21], Arthus’s phenomenon (22) and ona: phylaxis{23a, 23b) have also been reported, PURIFICATION OF THE ALLERGENS AND THEIR CROSS REACTIVITY Ithas been idenifed « rather large number of IgE bin- ding allergens ranging From 20 ¥Da to 70 KDE using «@.saliva venom which is obviously technically dificult to obtain, As far as we know only two purified and characterized cllergens have bean described: Aad o 1: (68 kDa apyraseland Aed 2 ( 37 kDa ) from Aedes ‘Aegypli Titty seven polypeptides ranging from 16 to 120 KD have been found in whole body exiracls of ‘Aedex and Culex species (Wu, 24). Fewer bands have bbeen detected in saliva with a 62 kDa compound com- mon fo the five mosquito species examined (Shen, 25). lis known that there are cross reactive ond species specific allergens. We do not know exactly what is ial cbarenl sires lRecivih ooreenfen ists hand Aedes communis and on the other hand Culex pipiens ond Aedes Albopictus. Peng (26) found stu- dying 10 mosquito species (Aedes (Ae.) aegypti, ‘Ae. vexans, Ae. albopictus, Ae. togoi, Ae. triseria tus, Culex (Cx) quiquefasciatus, Cx pipiens, Cx. tar- salis, Anopheles’ (An.) sinensis, and Culiseta [Cs] inornata) that the species shared allergens are more importent than the specific ones NATURAL HISTORY According to Mellanby, the natural history of cutaneous Sa eae easiaed ores tern (table 2) First, the bles cause no reaction {stage 1), next (sage 2} oppears a delayed reaction, third both immediate and delayed reactions are induced (stoge 3}. Then (stage 4) there is only an immediate reaction, Finaly af tage 5. no reacion occurs, However since, it ie not known who iz the average lapse of me, which is probably more or less long according fo subjects, between the Fret mosquito bite cand the appearance of tolerance {stage 5) @ specific immunotherapy seems fo us jusified. I! oppears thot there isin general a notural hyposensiization, Natural desensiization was carried out by Mc Kiel et af Fe SeTeH vel ery estieenre oven Saveredineat eter ted for the mojority of the subjects in an improvement REDUVIIDAE | PULICIDAE | CULICIDAE | CERATO | SIMULIDAE | TABANIDAE. POGONI DAE | SPECIES ‘cIMeX TRIATOMA | PULEX | CULEX | CULICoIDES | siMULIUM | GASTROPHILUS IRRITANS EQUINUM | INTESTINALIS tecTutanius | rrovacia | CiENO | AEDES CEPHALDES (HOUSE BUG) | (KISSING BUG) | (FLEAS) | ANOPHELES | Table 1: Inset classfcation, INBE | Tiss fexanomy of hematophogous insects {2} House fly belong fo the dptera order 132 +p om ay. European Annals of Allergy and Clinical Inmunalogy ~ vokme 36 — n° 4 ~ 2004 According to Palosuo (27) “about half of adult people who had lived exclusively in Finnish Laplant (subject fo excessive exposition} were tolerant. In southern Finland the corresponding figure was about 5%. li may take 20 years or so in temperate zone countries" Since it was not possible to have cn extrac both species and owing to the cross reactivity between the different species, we used in this sudy cn extract of Aedes Communis. The extract contained both saliva venom ond whole body Its known that there is in general no cross reacivty between the venom and the Proteins contained in the whole bod, However, years a) Hater reas iy chhaving puriied Van for hymenoplera stings allergy, many allergists used in this case, the whole body of the identified insects Since naturally acquired desensitization to mosquito bites occurs after a long term exposure and since seve- ral rather successfull atiempts of S11. have been car- ried out for a long time, we tried fo cure this way some of our patients who had annoying painful reactions The “natural” desensitization is related to an increase of specific lgG4 antibody to the specific antigens. It seemed to us tho! S..T would help Nature as we have already shown with parietoria judaica pollen SLT {28}. As a matter of fact we found in the literature only thirieen papers dealing with 5.1.1 for mosquitos bites allergy:the results obtained were in general favorable (29-41). There is a good review on this topic by Hemmer and Jarish (42) In spite of these drawbacks we started to treat a few patienls; then, after the good results obtained at the beginning, we reached the number of 20 patients who cre the object ofthis study, The aim of this study was to confirm this data and find cout whether the efficacy of immunotherapy could be extended to concomitant respiratory reaictions The five — stage sequence of skin ré z MATERIALS AND METHODS PATIENTS 20 patients were accepted for inclusion in our study, the mean age was 26 years. An homogenous control group, of tae 10 patients, was selected. In the acti- ve group, we have eleven women and nine men, the control group was composed of an equal number of men and women, An informed written consent was obtained from all tha patients in boths groups. Al these patients reported episodes of persistent pruri- gineous lesions offen painful several hour aftor being Bitton by a mosquito ; the local reaction was between 4 to 10 cms (average diameter) ond lasted 24 to 48 hr. Besides, in spring and in summer, they had persis- tent rhinitis (19 cases associated in 6 cases with a mild asthma). One of the patients has conjuctivitis. Moreover all of these patients had positive skin prick test and RAST to mosquito (Aedes communis, Stalléegenes) and also positive Nasal Provocation Test to this allergen (table 3) Other sensitivities (mites, weeds and trees pollens and animal danders) were not exclusion criteria, . None of them reported clinical reactions to the stings of horse fly (Tabanidoe), black fly |Simulidae}, flea, Hymenoptera or other unidentified insects Subjects with o disease that would interfere with the evaluation of clinical symptoms, such as rhinitis medi- camentosa, sinusitis or large obstructive nasal polyps, pregnancy’ or breast feeding, and serious systemic disease, were discarded. ALLERGENIC EXTRACTS Al of he exacts were, supplied by Siollrgenes Laboratories (Paris, France). The ollergen preparation s ty in hosts exposed to repeated mosquito feeding* | STAGE | (NON SENSITIZED) STAGE It STAGE It STAGE IV STAGEV (TOLERANCE) Table 2: Notural immunological development of mosquita'sbites, * After Mellonby and Mc Kiel 134 ACTIVE GROUP as ia are a) Cane aco len ep SC acs iE car 4 DPF OE BLA GI Zale 3 Ti DPF CU 3 | M 3 7a | DPF CU ala 4 is [4 PAGR BE BLA GI S| F 4 sim] DPF PA OE BLA Gi] 6 | é ss |b ved DPE BLA GI aw 4 Silt PAGR CU_ @[F 3 Daa assole DPF BLA Gi 3 | ™ 3 ine GR DPF GLA Gi o|__F ae 3 No. mF 3 3 FF Gr (pal a 4 3 Ne | 3B] 4 [6a a a [ia] 3 20 [3 Gi | _¥ 3 a laa DEF ALA GI | TST BAG i7|_¥ 3 ra aa ecu AG | pve cae | DPF BLA, | 4 ZOE) PABLA GI 2 |r 3 Ea (CONTROL GROUP) ia PRICKTES eee i] 3 2 | 4 DPF PA BE BLA GI a | 4 Sona GR PA OF GI 3M 3 16 DPF BLA GI 4 F BRET Wis isa DPF BLA GI scaler 4 3 : = i fe] 2 33 FBLA GI 7 TPR [TI 38 PAGRBE BLA GI a) Sez No [9 Esat 3 cl ie ' ue Gi 05 a | 20 L Gi (LEGEND) ‘A | ASTHMA DPF| _DERMATOPHAGOIDES PTERON, OR FARINAE AR| ALLERGIC RHINITIS. | CU | CUPRESSACEAE © | conjuncrivins | Be | BeTULAALBA GR) GRASSES POLLEN | BLA\ LUA GERMANICA OE] OLEAEUROPEA | GI_| GASTEROPHILUS INTESTINALIS (HORSE FLY) PA PARIETARIA JUDAICA Table 3: Clinical data of our patients 134 was based on Good Manufacturing Practice (GMP) with an inhouse reference standard. An allergenic extract is defined as 100 I.R. ml when, used by prick: test using a STALLERPOINT on 30 subjects who are sen- sitive tothe allergen, it gives a weal size of 7 mm (geo: metric mean). The skin reactivity of the subjects is simul- taneously shown with 9% codeine phosphate or hisia~ mine chlorydrate at 10 mg/taken as a positive control However, we did not know what was the percentage of saliva venom in the whole body extrac used in this study. It is obvious that, for the collecting of saliva venom is currently too tedious and impractical, « new method of standardizing the extracts from whole body should be found. As suggested by Peng et al. (43) mosquito! = head and thorax contained more saliva proteins. SKIN TESTING The prick testing was performed according to the method of the subcommittee on Skin Tests of the European Academy of allergy and Clinical Immunology using standardized lancets [Dome Hollister Stier, west Haeven, CT, USA), We adopted the following scores: a 3+ reaction cor- responded io the weal and erythema of histamine (1 mg for the T-ml prick tes!). A 4+ reaction corres ponded fo a reaction greater than that caused by his famine. A 2+ reaction was 75% and a 1+ reaction was half the size of he histamine reaction Histamine hydrochloride (mg/ml) and buffer solution were tested as controls of positive and negative skin reaction respectively. The distance between test sites of Histamine and Aedes Communis was more than 5 cm. ‘Skin prick test results were recorded after 15 to 20 minutes. The mean weal diameter (MD) was calcu- lated according to the formula (D+ d}/2 where D represents the largest (longitudinal) diameter and its midpoint orthogonal ameter ‘Skin pric tests (SPT) were performed with the commo: nest inhalant allergens (Dermatophagoides pteronyssi- ‘nus, Parietaria judaica, Cynodon dactylon, Lolium per enne, Olea europea, Artemisia vulgaris, Ambrosia ele: tior, Cupressus sempervirens, Alternaria altemata, Cat, Dog). The following insects besides Aedes communis were included in this panel: Aedes communis, Blatella germanica (german cockroach], gaslerophilusinfestin Ts (horse fly). Table Il shows the clinical data correspon: dling to the 20 patients of the treated group and the 10 Patients of the control group. All the patients had a posi- tive skin fest and RAST to asthma, With the same extra ct, we had in all cases, « positive nasal provocation test. IN VITRO TESTS Specific serum IgE determinations were performed by enzyme immune analysis CAP FEIA [Pharmacia - Upjohn Uppsala Sweden) using an extract of Aedes communis and following the manufacturer's instruc tions. Specific IgE equal to or higher than 035 KU / 1 ‘was considered positive. NASAL PROVOCATION TEST A specific nasal provocation test was carried out on all patients, before and after treatment, with on extract of Aedes Communis, The extracts were used at several concentrations: 1, 10, 100/ml (with non phenolated saline diluent and spray of 100 microl/constant volume). The patients had to be symptom-free. Tests were performed with instillation with a pressurized spray into one nostril of increa- sing concentration at 15 minute intervals, A control test with diluted buffer was performed into. the opposite site. The threshold dose of allergen able 10 ler iver uf ato ihel Merete aed toms (sneezing, obstruction, itching, thinorrea) was determined fer two peak inspiatory ow meter measurements. We used the Youlton peak inspirato: ry flow meter (PIFRn meter}. It offers some advan- tages over the expiratory flow rate moter especially when used in provocation test and it is easier to handle compared with standard chinomanometry. The results are expressed as the mean valves of three consecutive rogistrations. A test was conside- red positive when we observed e drop in the basic value of 20% and/or elicit at least two symptoms among the four followings: sneezing, obstruction, itching, rhinorrea BITE CHALLENGE PROTOCOL This tochnique which is rather cumbersome was not carred out in our study for the obvious reason that the field bites were negative in all the treated cases. H Specific immunotherapy (SIT): Specific immunetherapy with a mosquito whole body extract (Aedes communis} was initially carried out with weekly subcutaneous injections, beginning at a concentration of 0.01- 1 1,8. and increasing the dose progressively for two months, according to the follo- wing schedule (lable 4) The’ maintenance treatment was carried out with weekly injections at a concentra- tion of 10 IC for fourteen month. The total lenght of treatment was 18 months and the cumulative dosage received by the patients was therefore 120 LR. INTIAL PTNet 0.1 Rt Mainvenance concentrate (monthly) | 10 IRint 080 Table 4: Schedule of treatment I Symptom and drug scores: Symptom and drug scores were recorded daily on a cart. Rhinits ie, sneezing, pruritus, nasal discarge, nasal obstruction was scored 0-3. Eye redness, itching, tears and swel ling were also scored 0 to 3, 08 well as cough, whee. zing, sputum, breathlessness. A score 0 indicated absence of symptoms. Drugs taken were scored with 1 point for every administration. WH Statistical analysis: Statistical evaluation was done by Mann-Withney U-test (two tailed probabili- ties) for the intergroup comparisons and the Wilcoxon signed rank for intragroup comparisons at the diffe rent fime of observation. The chi-square test was used fo test the significance of differences among the overall evaluation stated al the end of the trial. The level of significance chosen was p<0.05. RESULTS After 18 months of immunotherapy all the 20 patients, who received the specific immunotherapy, reported the disappearance of persistent cutaneous lesions and res piralory or ocular sympioms after been bitten by a mosquito, On the contrary none of the 10 patiens in the control group, who have not received the treat. gitis We did not carry out a contr ¢hallong before ond ofr here in the active group reported to reaction afer being stung, rolled mosquito bite ment but no patient have experiences any Moreover, at the end of the treatment, we observed a statistically significant improvement of symptom and drag consumption scores, only in the active group and not in the control group. The data are shown fo the table 5. with the results of statistical anclyss, with Wilcoxon test. Also the intergroup comparisons, with MannWitney U-test, showed an significant difference bohwaon the Iwo groups, before the treatment. Moreover, a significant increase (p<0.05) in the thre: shold dose to specific nasal challenge in comparison with baseline values was observed in actively treated group but notin the control group, after the period of trealment (table 6) All potients completed the period of 18 months of immunotherapy and no local or systemic side-effects were reported in the active group. 643 (64351) | Peo. 2.43 (2.15) ‘ACTIVE | Symptoms | 18.14 (64 261) GROUP | Drugs | 5.29 (sd 2.15) CONTROL| Symptoms Grour | Drugs 1880 (ed 2.68) 5.60 (ed 1.14) 1880 (54268) | Ne 5.40 (540.99) |e Table 5: Moan monthly symglom ond ceug scores in eclve end control before and after the eclment * Wileoxen fet NS: Not sgaificant sd: standard deviation ACTIVE GROUP. CONTROL Gi Gen. ere | 80 (642.74) S a MEAN 7.86 DOSES (66 2.67) lo Difference Table 6: Changes in nasel provocation ess in both groups before anc the Weaiment *p<0.01 Wilcoxon tet ‘de standord deviation DISCUSSION with whole ‘extract has already been practi- SUT wih whole body erat has ckeady been prod Mean Whilney Utes ot signifi 3, Feinborg A-R, Feinberg S.-M, Benaim-Pinto C. - Asthma ond thinis from insect allergen | Clinical importance. J Allergy 1956; 27 (5):437-444, oat Peace Re phir Glaey ielalicopods io the Seclusion ‘i mies). Port), Allergol et mmunopothol. 19942214): 28-38, Sea reed ciaianiiclec) oicrtreoob lio exchsion ‘of mites). Port Il, Allergol et Immunopathol. 1994;22{4):167-177, {6 Ponzoni R-C. , Aviano R. : Anhropods and invertebrates allergy {wih the exclusion of mites): the concept of panolergy. Allergy 300136 Sop 891-23, 7 Baldo BR Ponzoni®-C,-Detedion of gE onhodies oa wide ‘ong mec spcs in abs wih spaced lt legis fe hrcen, ln Arc Alrgy Appl muro! 1988, 98:278-287, SistrakrT, Bammer ecrlons FL PslesteT,Raide KE Moss Bes allergy. ACI internesional 1996,0/348'51 9. Brummer Korvenkontio H., Polosuo K., Brummer Korvenkontio IM, Lainilld , ReunalaT,- Détecion of mosquilo saliva specific IgE antibodies by capture Elisa. Allergy 1997;342-5, 10. Reunala T., Brummer Korvenkontio H., Résanen L, Frangois G., Polowio'T, -Possive Ironsfer of cutaneous mosquito bile hypersens! Say by lee ent salve onibodion J. Alergy Chin nmol 1994;94:902-06, 11, Reunala T,, Brummer Korvenkontio H., Lappalainen P., Réséinen LU Petree: hmrunolgy an reatent of mosqia ie. Chico! ‘and Exp Allergy 1990;204SuppI 4) 19-24. 12, Peng Z, Yang M,, Estelle F, Simons FER, - Immunologic mecho- rims in mesquite allergy: cordetion of skin reaction wath specific IgE ond ig entibodies nd lymphocyte profifleration response 10 resguio antigens. Ann Allergy” Asioma’ & Immunol, 199677 Psocbas, Ta, Agaiwal M-K,, Choudky S, thom S., Gaur $:N., Chovon UPS,, Agorwol HC. - Efelogie significance of mosquito (Anopheles stopkens) in respirctory allergy in India. Ann Allergy 1991;67:59- 02 1 Mellonby 1946; 158.534 15. McKiel J.A,, West A.-S. - Nature and causation of insect bite teocion. Pediotc Clin North Am 1961;8:795.816 16, Valentine M.-D. - Insect- sting anaphylaxis. Ann Intern Med 1993;118:295-226 17, Reel, Brummer KorverkontoH, Palos K, Mini M., live A. Frengbis G.,PolosuaT.- Frequent occurence of Ig ond 1gG4 cnibodies against soliea of Aaces communis ond Asdes meri aceaiioenntcikiea Kt Ac Alergy. tinal TE od 360-371. 18. Reunala T,, Brummer-Korvenkontio H., Lappalainen, Reunala T. ee ee se epee cael ga cetbaates by immunabloting. J allergy Clin Immunol 1994,93:551-5, 19. Frazier C.-A. - Biting Insects. Arch Dermatol 1973;107: wo0-4b2 20. Simons FER., Peng Z. - Skeeter syndrome. J. Allergy Clin immune! 1999, 1047087, 21, Walker G.-B., Harrison P.-V. - Seasonal bullous eruption due to presqoes Cin Exp Dormotel 1985, 10:127-132. 2. Brow A, Guts THD, En fa Aru’ pheromaren ry mesquo bles, Report of a case wih experimental suds Souk ned 1738;31500, 23. McCormack, Salata K.f., Hershey J.-N., Carpenter G.-B., Engler R.-J. -Mosquito bite anaphylaxis: immunotherapy with whole body exer, Ant Alergy Astin Immunol 19957743944, 23, Hassoun &, Drovet, Sabbch = Anopylxs lo Mosquilo: Report of two clinical cases. Allergie ef Immunol 1999;XXXI 8:285-287. 24, Wu C-H., Lan J.-L. - Immunoblot analysis of allergens in crude mosquilo extracts. Int Arch. Allergy Appl. Immunol 1989;50: ‘Mar’s resction fo mosquito bites. Noture 25, Shen HD. Chon CC, Chong HN Chang Lv 1 WC ion 5-H. ~ Himan IgE ond IgG onibodies to posauto proteins detecied by the immuncbltlechnque. Ann Alergy 1959363 143-6 26. Peng Z_, UH, Simons FER - lrmuncbl ones savory ole gern YOmesqu spaces wih worded dahon he hanon gE responses to the alegre. J Allergy Clin Inmncl1998;101:496-505, FF Palos, -Perschnel commen, 28, Ponzoni R-C, Ariane Rey Augeri G. ~ Monitoring of specific IgG enibodia it espircory clltgy doe to the pal of Peritria teoica, Bidence for a protective ae. Alergol of immunopetial oe 2416}.265-268, 29, Benson RL. - Diagnosis and treatment of sensization to mos vies Allergy 1936,8-47-57, 30, Benson ReL- Diagnosis of ypersensiveness othe bee andl io the moxlio, wih report on socal specie. Wecierd. Arch, Injen, Med. 1939,84.1306"1327 31. Peron f= Insect as allergen in injectors. California Med 19629619 fies ok lores 32, ager A, Lass N,, Gold D. - Studies on Culex pipiens molest insta. nt Arch Allergy 1969;°36406-14. 33, Gluck JG, Pocin MP Asthma from mosquito bles: 0 cose reper. Ann Allergy 1986; 8-47-57 32 bencinFintoC, Fasstainer A. nrodermalimmunetheropy in chien with severe skin inflommatory reacons to Aedes oegypl end Culex quinquelaiokss mesrpito Hes. nt J) Dermatol 1990,29:600'501 35, Hahnstod RL, Pires MG - Diptera (Mosquita) allergenic extra

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