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Diagnosing Enzyme-induced Asthma With A Challenge Test
Enzymes cause the following clinical symptoms and diseases typical of type I hypersensitivity: asthma, rhinitis, conjunctivitis, and urticarial skin symptoms. Guidelines have been introduced for the diagnostics of occupational asthma (Subcommittee on Occupational Asthma of the EAACI 1992). The recommended five steps were as follows: (1) history suggestive of occupational asthma, (2) confirmation of asthma, (3) confirmation of work-related bronchoconstriction with serial measurements of peak expiratory flow rate (PEFR) and confirmation of non-specific bronchial reactivity, (4) confirmation of sensitization to occupational agents, and (5) confirmation of the causal role of the occupational agent with specific bronchial challenges. The bronchial challenge test is regarded as the gold standard in the diagnosis of occupational asthma (Pepys & Hutchcroft 1975, Nordman 1994a, Chan-Yeung & Malo 1995, Cartier 1998, Cartier & Malo 1999). It is superior to PEFR in specificity and preferred especially when there is uncertainty about the causative agent or the agent is a “new” sensitizer or the patient history indicates severe symptoms, and uncontrolled PEFR monitoring is not regarded as being as safe as a controlled challenge test. Challenge tests with enzymes have been performed with a variety of protocols (Table 5). Basically, there are two different methods. One is to generate an aerosol or dust and inhale it through a special device. Another is a protocol in which the substance to be inhaled is generated into the free space (in a challenge chamber), where the subject inhales the dust.
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