ST. JMC JOURNAL OF MEDICINE ISSN 0970-4221 VOL.III NO. 4 DECEMBER 1990

Item

Title
ST. JMC JOURNAL OF MEDICINE ISSN 0970-4221 VOL.III NO. 4 DECEMBER 1990
extracted text
COMMUNITY HEALTH CELL
326, V Main, I Block
Korambngala
Bangalcre-560034

India

ISSN 0970 - 4221

ST. JOHN'S MEDICAL COLLEGE

JOURNAL OF MEDICINE
VOL III No 4

December 1990

EDITORIAL

96

DERMATOLOGY SYMPOSIUM - ALLERGY

Foreword

100

Abstracts

101

Food

105

Allergy

Practical Skin Test, Procedures in Allergy I - Patch Testing

108

Practical Procedures in Skin Tests for Allergy II - Prick Testing

110

REVIEW

Autologous Blood Transfusion : Its role in Oral and Maxillofacial Surgery

112

EDITOR-IN-CHIEF

INFORMATION FOR CONTRIBUTORS

!

Ashley. J. D'Cruz

Submitting the Manuscript

EDITORIAL BOARD

The St. John’s Medical College Journal of Medicine accepts scientific contributions from all fields of
modern medicine and from all institutions and health care professionals. The journal is a quarterly
publication which will be published in March, June, September and December. It is owned by the
C.B.C.I. Society for Medical Education and published by the Principal, St. John’s Medical College, The
journal is a part of it’s commitment to continuing medical education. Articles and all editorial
communications should be addressed to the Editor, Alumni Office, St. John's Medical College,
Bangalore-560 034.

Rajini Macaden

Ravi C. Nayar
Mario Vaz

Original articles, short case reports and review articles are accepted for publication. Review articles
and editorials are usually on invitation by the Editorial Board. Letters to the Editor will be considered
for publication only if received at least six weeks prior to the next publication.

A.B. Kilpadi

PREPARING THE MANUSCRIPTS

A.S. Arvind
Anil Abraham

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The format for articles suggested is as follows: INTRODUCTION, MATERIALS AND METHODS,
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Measurements should be in metric system.

OVERSEAS

R.R. Baliga
A.V. Kurpad

ILLUSTRATIONS AND TABLES
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REFERENCES

PUBLISHER

Prof. A.F.A. Mascarenhas
Principal

References should be compiled at the end of the articles according to the order of citation in the text,
not alphabetically. They should be typewritten, double-spaced under the heading REFERENCES.
Abbreviation for titles of medical periodicals should conform to those used in the latest edition of Index
Medicus. Give inclusive page numbers.
EXAMPLES OF REFERENCES

Journal Articles upto six authors, list all names:
Kurpad AV, Shetty PS: Dietary Fibre and the colon. SLJohn's J Med, 1988;1:5-12.
Journal Articles more than six authors, list three authors followed by et al:

Complete book
Gallagher JR: Medical Care of the Adolescent (ed 2). New York. Appleton, 1966; pp 208-215
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St. John's Medical College Journal of Medicine

EDITORIAL
LIVER SURGERY : PRESENT AND FUTURE
INTRODUCTION

Till recently the liver, despite being the largest organ in the body, remained elusive. Its functions were inadequately
understood, surgery was regarded as foolhardy or unnecessary, and the diagnosis, when possible, was an academic and
often fatalistic exercise. While hepatitis was, and remains the commonest affliction, the last two decades have seen significant
advances in the diagnosis and treatment of focal lesions of the liver.

Asian countries have an endemic prevalence of the hepatitis viruses, and a correspondingly high incidence of both hepatic
malignancies and cirrhosis. As populations in these countries are high, primary hepatic cancer is now the malignancy affecting
the maximum number of people in the world. Not surprisingly, a number of the advances in liver surgery have come from
countries of this region.
With the establishment of liver transplantation in the eighties, the future promises to witness increasing attempts to treat
disseminated diseases of the liver like cirrhosis, acute and chronic liver failure, and congenital disorders of metabolism.
While the majority of digestive surgeons seem reluctant to subspecalize, it is time to take stock of liver surgery. Along
with immunology and virology, the study of liver diseases represents the cutting edge of science today.

ANATOMY
The segmental anatomy of the liver as outlined by the French surgeon Couinaud forms the basis of all liver surgery, and
is now the standard format used in all radiological and surgical descriptions.

The liver is in reality two livers - the right and the left - each having four segments, which are numbered serially from I to
VIII starting with the caudate lobe posteriorly and going from left to right. Each segment possesses its own arterial and portal
venous supply, and is drained by its own bile duct. The venous drainage to the inferior vena cava is, however shared by
adjacent segments: the left hapatic vein running between segments II and III of the left liver, and the right hepatic vein running
between the anteriorly located segments V and VIII, and the posteriorly located segments VI and VII of the right liver. The
middle hepatic vein runs in between the right and left livers, and its course can be marked on the anterior surface (at surgery)
by an imaginary line running from the gall bladder fundus in front to the inferior vena cava behind. The hepatic veins are
easily visualised on ultrasound scanning, and help to precisely localise focal lesions of the liver.

The importance for the surgeon of recognising the segmental nature of the liver, lies in the fact that while it is easy to
surgically remove portions of the liver, what is much more difficult is to ensure the viability of the liver tissue that is left
behind. It is deceptively easy, during a major liver resection, to “get lost” in the liver substance and end up compromising
the vascularity or the venous drainage of the remaining segments.
For the physician, a familiarity with the segmental anatomy is necessary for a meaningful surgical referral. A known cirrhotic,
for instance, who decompensates with the development of a liver tumour, would probably not be a candidate for surgery
if more than two segments are involved.

IMAGING

With the knowledge that most focal lesions of the liver are not amenable to medical therapy, the trend in the 80s has shifted
to diagnosis by imaging rather than histopathology. It is now possible to achieve a reasonably accurate pathological
diagnosis while delineating the anatomical and physical characteristics of the lesion by ultrasound and contrast enhanced CT
scan. Biopsies are at best a hit or miss affair, and even if successful in obtaining enough tissue for a pathologist to commit
himself are an academic exercise best reserved for patients who are not candidates for curative therapy. This philosophy
is outlined in Fg. 1.

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St. John’s Medical College Journal of Medicine

Fig 1 : Segments of the Liver

THE RESECTIONS
FOCAL LIVER LESION

ultrasound scan

f---

± CT scan

CYSTIC

r~

patient
septic

J----

T

T

HYDATID
CYST
± positive
serology

CONGENITAL
LIVER CYST/
POLYCYSTIC
LIVER

SOLID

ATYPICA
CYST

SOLITARY

I

J-------

NO METASTASES
Chest X-ray/bone scan

DISTANT
METASTASES

!
CT scan
PYOGENIC/
AMOEBIC
ABSCESS

appropriate
treatment:
1. percutaneous
aspiration
2. antibiotic/
amoebicidal
therapy .
3. percutaneous/
surgical
drainage

I------symptomatic/
complicated

4
uncomplicated/
asymptomatic

heavily
HAEMANGIOMA
calcified/
asymptomatic

MULTIPLE

I

angiography
asymptomatic/
little risk
tumour
symptomatic/
circulation/
risk of rupture
avascular
lesion

? trial of
medical therapy

embolisation

IV cavogram

4
surgical treatment

usually no treatment,
assess renal function,
occasional surgery

observ

appropriate
non-surgical
treatment

‘

operative assessment
± resection
± biopsy

PATHOLOGICAL
DIAGNOSIS

biopsy
1.FNAC
± US/CT guidance
2. Laparoscopic
needle biopsy
-3. Percutaneous
needle biopsy
± US/CT/angio
guidance

Fig 2: Investigation of a focal liver lesion

December 1990

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St. John’s Medical College Journal of Medicine
Based on the hepatic segmental anatomy, the liver resections are (Fig.2):
LEFT LOBECTOMY: Segments II and III, i.e. the liver tissue to the left of the falciform ligament.
LEFTHEPATECTOMY: Segments II, III and IV, i.e. the livertissueto the left of the cholecysto-caval line. Segment I (caudate
lobe) is included when required by the anatomical extent of the lesion.
RIGHT HEPATECTOMY: Segments , V, VIII, VI, and VII, i.e. the liver tissue to the right of the cholecysto-caval line.
EXTENDED RIGHT HEPATECTOMY (syn.: RIGHT TRISEGMENTECTOMY): Segments V, VIII, VI, VII, and IV, i.e.
the liver tissue to the right of the falciform ligament.
EXTENDED LEFT HEPATECTOMY (rarely performed and hazardous) Segments II, III, IV, Vand VIII i.e., the liver tissue
to the left of the right hepatic vein.
Apart from the above mentioned standard resections, resection of segments both singly and in combination have been
described, especially in the mangement of cirrhotics who may have more than one tumour, and are unable to withstand a
standard resection.

Liver resection may also be required for bile duct tumours infiltrating the hilar structures supplying one half of the liver,
or for direct infiltration of the liver parenchyma at the hilum. The difference from the same resection performed for a primary
hepatocellular lesion is that in this situation the patient is jaundiced and the resection removes a sizable mass of normal
liver tissue. The physiological derangements in the operative and postoperative period are therefore much worse.
PERIOPERATIVE MANAGEMENT

Child’s criteria constitute a time honoured method of assessing the degree of disability of a patient with liver disease. While
Child’s C patients are an easily recognised group at major risk for any kind of surgery, risk allocation in better preserved
patients is an area of ongoing research. BSP retention, glucose tolerance test, measurement of Factor II and V levels
and estimation of the amount of “cytochrome a” in a liver biopsy specimen, each have their proponents. It is becoming
increasingly clear, however, that perhaps the most sensitive prognostic indicator is the patient’s history. Chronic liver
disease resulting in significant impairment of the patients lifestyle, with dimunition of intelligence and physical vigour carries
a grave prognosis.

Resection of a large mass of liver tissue is well tolerated only if at least 2 normal segments of liver are left behind. The
diseased liver is extremely sensitive to ischemic injury which may follow the impairment of liver blood flow under anaes­
thesia or result from surgical interruption of the blood flow to whole or part of the liver. Clinical manifestations are subtle, and
may take the form of respiratory, renal and /or cerebral dysfunction. Hypoglycemia, hypoalbuminemia, hyperbilirubinemia,
abnormal clotting, alkalosis/acidosis and electrolyte abnormalities are associated. Intensive care after major liver surgery
involves monitoring of all haemodynamic and metabolic parameters.
Based on this mass of data decisions regarding the use of fluids, blood, blood products, dialysis and ventilatory support
and combinations of drugs like dopamine, dobutamine, nitroglycerine, nitroprussided and noradrenaline, to name only a few,
have to be made. Parental nutrition is often required since there may be problems associated with the use of the G.I. tract
for enteral feeding.

Perhaps the most dangerous of all complications in the acute phase is the rapidity with which these patients tend to develop
severe hyponatremia, and its dreaded sequel of cerebropontine myelolysis. The immunological impairment that
accompanies liver surgery requires a major input from the microbiologist - an important member of the clinical team
-who decides the antibiotic strategy, and the surveillance for viral and fungal and resistant bacterial superinfections, that
are associated with the use of broad spectrum antibiotics.
FUTURE TRENDS
There is now sufficient evidence on long term follow up to justify an aggressive approach to liver tumours-both primary
and metastatic. The future will see increasing attempts to offer resection to centrally located liver tumours, and to tumours
associated with cirrhosis, which are presently regarded as technically inoperable.

Initial attempts to resect massive central liver tumours in children under cardiopulmonary bypass with hypothermia have
been successful. The experience with liver transplantation has led to large and multiple tumours in adults being managed
by excising the entire liver, and on the back-bench resecting the tumour and reconstructing the liver before re-implantation.

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St. John's Medical College Journal of Medicine
There is renewed interest in transplantation for tumours of the liver and extrahepatic bile ducts. While the former is performed
under chemotherapeutic cover, the latter is being tackled with “cluster transplants” in which the liver, pancreas and
duodenumare transplanted as one complex following total and radical resection ofthetumourwhich is usually slow growing
and'Slow to metastasis. Improvements in immunosuppressive drugs which selectively suppress organ rejection while
leaving unaffected the ability of the body’s defences to cope with distant micrometastases would further open up this
field of surgery.
Orthotopic Liver Transplantation promises to find increasing application in the future. Congenital diseases like haemo­
philia are cured by transplantation, and in future liver transplant may be offered to such patients despite the fact that the liver
is not “diseased”. Fulminant and subhepatic failure irrespective of cause, are an increasingly common indication for
transplantation. To keep the patient alive till a suitable organ is available, the diseased liver is excised and the patient
supported with intensive care until transplantation, which is usually performed within 48 hours.
The chief limiting factor is the increasing shortage of cadaveric organs, and as the demand for liver transplants is only likely
to increase, attempts at xenografting are being made. The liver enjoying as it does an immunologically favoured status,
would be one of the first organs to be transplanted from other species if advances in immunosuppression permit.
Dr. Philip G. Thomas
Assistant Professor
Department of General Surgery
St. John’s Medical College Hospital
Bangalore

SELECTED REFERENCES
1.

Bismuth H. Surgical anatomy and anatomical surgery pf the liver. World J.Surg. 1982;6:3-9.

2.

Di Bisceglie Am, et al. NIH conference: Hepatocellular carcinoma. Ann. Int. Med. 1988;108:390-401.

3. Lee CS, Sung JL, Hwang LY, et al. Surgical treatment of 109 patients with symptomatic and asymptomatic hepatocellular carcinoma. Surgery 1986;90(4):481
489.
4.

Bismuth H, Houssin D, Ornowski J, Meriggi F. Liver resections in cirrhotic patients : a western experience. World J Surg. 1986;10:311-317.

5.

Starzl TE, Demetris AJ. Liver transplantation : a 31 year perspective. Curr. Prob. Surg. 1990;Vols2-4:55-240.

December 1990

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St. John’s Medical College Journal of Medicine

DERMATOLOGY SYMPOSIUM - ALLERGY

FOREWORD

Allergy Diseases have not yet achieved their due importance. Although
Allergy Diseases, are rarely life threatening they have a considerable impact
on health and development. Further, there is increasing evidence that the
prevalence of these diseases is steadily increasing in the population. Allergy
Diseases are of high complexity both in their clinical manifestation and their
etiology. One of the main intentions of this symposium therefore is to present
information on various aspects of these diseases in order to understand the
causative factors. In addition, it is to demonstrate tests that help diagnose
some of them.

To this end we have an excellent faculty both invited and from our institution
to deliberate these matters. I do hope that the deliberations of this National
symposium will generate lasting interest among the participants. More
importantly I hope that for the future, efforts of this symposium will establish
a rational approach in the field of Allergy in our country.

I would also like to thank my colleagues for their support and co-operation
in making this symposium a success.

Dr. S.C. Rajendran, MD DVD

Organising Secretary

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St. John's Medical College Journal of Medicine

ABSTRACTS

DERMATOLOGY SYMPOSIUM - ALLERGY
ETIOPATHOGENESIS OF BRONCHIAL
ASTHMA
Abstract
Bronchial asthma is a common cause of respiratory
morbidity. Central to the problem of asthma is reversible
airways obstruction which is triggered by a variety of stimuli
such as allergy, infection, excercise, climatic changes,
emotional factors, drugs and others. In recent years, there
has been rapid increase
in
understanding of
the
phenomenon of airway hyperreactivity both in terms of
physiology and immunology. The concept that asthma is
related more to inflammatory changes in the airways rather
than to ‘bronchospasm’ alone has been appreciated. The
role of the chemical mediators in the the immediate as well
as the Late Asthmatic Response (LAR) has been elucidated
elegantly. This aspect of improved understanding is
important not only academically but also at the clinical level.
The role of the cellular factors is demonstrated by the aid
of techniques such as, bronchoalveolar lavage.
Measurement of airway responsiveness and its
relationship to the severity of asthma has been important
in formulating therapies with improved outcome in cases of
patients.

whether such an epitope is in the soluable form or as part of
virus or bacteria, needs elucidation. On the other hand, T cell
receptor can ‘see’the antigen, only when it is processed
and presented in conjunction with major histocompatibility
complex (MHO) of class I or class II molecule. The antigen
processing and presentation is performed by macrophages
and B cells, in general called APC or antigen presenting cells.
One subpopulation of T cells-CD8 positive cytotoxic T cells
recognise the antigen (eg., cell surface bound viral antigen) in
conjunction with class I molecule, resulting in specific killing of
the target cells.

The major event in T cell biology is the clonal activation of T
cells by specific antigen. This phenomenon is MHC class
II restricted. As a result of the interaction between CD3/
Ti complex, and epitope-class II molecule, the T cell is
activated ultimately causing such T cells to proliferate. In this
process, new molelcules (lnterleukin-2 receptors) are
expressed and growth factors like lnterleukin-1 (IL-1), and IL2 and Interferon are synthesized by the interacting cell
populations. Further, we have been able to explain T-B
cooperation or T cell help at molecular level. The present
understanding on the T and B cell recpetor* antigen
processing and presentation by APC, early activation events,
growth factors will be described.

Dr. Om Prakash
Consultant Physician
St. Martha's Hospital
Bangalore

Dr. V.R. Muthvkaruppan
Department of I Immunology
School of Biological Sciences
Madurai Kamraj University

Madurai

MECHANISM OF ANTIGEN RECOGNITION BY
LYMPHOCYTES
According to the Clonal Selection Theory, each lymphocyte
is precommitted to recognise a specific antigen. This is true
for both T- and B- lymphocytes and the phenomenon of
commitment takes place in thymus for T-cells and in bursa
of Fabricus/bone-marrow for B-cells, involving gene
rearrangements to generate diversity.

On B cells, membrance bound immunoglobulin-M (migM)
is the recognizing molecule. On T cells, the T cell receptor
is/the heterodimer or CD3/Ti complex. In both T and B cell
receptor molecule, the variable region is responsible for the
specificity of antigen recognition. In addition, accessory
molecules aid in antigen recognition for T cells.

There is a major difference in antigen recognition between
T and B cells. slgM behaves similar to serum IgM, binding
specifically to antigenic determinant or epitope. In other
words, B cell receptor binds to antigenic epitope directly,
December 1990

PRINCIPLES AND STRATEGIES IN THE
CLINICAL MANAGEMENT OF BRONCHIAL
ASTHMA
When one considers strategies of any kind, the first step is
to make the participants fully aware of the action and its
consequences. This is of vital importance when one embarks
on the treatment of a disorder like Atopic Bronchial Asthma,
steeped as it is in myths and misunderstandings. The patient
must be educated as to the true nature of the disorder, the
present therapeutic options and their implications in order to
ensure their utmost co-operation before embarking on any
kind of drug treatment.
The therapeutic options are few, but used judiciously can
control the symproms in virtually all patients. The available
drugs can be divided into the following groups.

1.

Phospho-diesterase inhibitors.
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St. John's Medical College Journal of Medicine
2.
3.
4.
5.

Beta-adrenergic agonists.
Atropine derivatives
Corticosteroids
Others eg: Sodium cromoglycate and Ketotifen

ABSTRACTS
the therapeutic armamentarium at our disposal to-day this
is not a dream but a reality.
Dr. A. S. Chitnis
Senior Consultant, Jaslok Hospital

The use of theophylline group of drugs (principal phospho­
diesterase inhibitors) in bronchial asthma is controversial.
However, other functions ascribed to these agents have
recently revived their use, particularity as adjuvants to the
Beta-adrenegic agonists.

Beta-adrenergic
agnoists and Ipratropium Bromide
(atropine derivate in common use today) are the most widely
used agents for treating bronchia asthma and for status
asthmaticus today because of the ability to deliver these
agents by the inhalation route as well as subcutaneous route
in the former. Aerosol therapy is preferred because of the
immediate onset of action and small quantities of the drugs
required which consequently produce negligible systemic
side effects - a strong plus point compared to the oral route.
Aerosols have revolutionised the treatment of acute and
chronic bronchial asthma and are today the firest-line drugs
in this disorder.
Corticosteroids are the prime drugs in acute exacerbations
where beta-agonists and theophyllines fail to control the
symptoms, and must be used rather than avoided. Their
usefulness far outweighs their unecessarily dreaded side­
effects. These agents in the aerosol form or as rotacaps to
be inhaled are the major drugs for prophylaxis both in adults
and children, though personally I prefer
sodium
cromoglycate for prophylaxis in children. Ketotifen, though
orally administered, has no therapeutic advantages over
sodium cromoglycate and because of its tendency to
produce drowsiness has virtually gone out of favour of most
therapeuticians.

A brief therapeutic outline can thus be drawn as follows:

Occasional mild attacks - beta adregenic aerosols or
tablets with or without theophylline.
2. Occasional severe attacks - as above but with short pulses
of corticosteroids during the attacks.
3. Chronic perennial asthma - cortocosteroid aerosol
prophylaxis with beta agonists and theophylline to be
added during intermittent exacerbations. To the un­
responsive Ipratropium bromide in aerosol form can be
added as well.
1.

Finally a word about diet and excercise. Apart from restricting
items with artificial colouring agents and preservatives and
certain food stuffs that cause dermal allergies in individuals,
no other diet restriction is realty necessary. When free of
bronchospastic attacks, excercise to its optimum level is
permissable. Bronchial asthma should be regarded as a
disorder and not a disease and individuals suffering from it
should be encouraged to lead normal productive lives. With
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Bombay

SOME SELECTED TOPICS IN CUTANEOUS
ALLERGIES
A large number of skin diseases are based on allergic/
immunological mechanisms, but in a limited period of time, it
is not possible to have a detailed discussion on all these
diseases. It is therefore proposed to pick up a few selected
topics among these diseases and highlight the latest
developments/experience in the respective areas.
Urticaria is the commonest allergic disorder and it can be
caused by a variety of agents. Food and drugs are well known
causes of urticaria, but a significant proportion of cases of
urticaria are caused by physical agents such as cold, heat,
sunlight, friction or excercise. We have developed two tests,
“Cryo-stimulationtest” for cold urticaria and “Dermograding”
for dermographic urticaria with which one can deliver
standardised and graded stimuli of cold and friction
■ respectively for confirming the diagnosis and grading the
degree of hypersensitivity in these two types of urticaria.
These tests are also useful for following the natural course of
the disease in these cases and also forobjectively
evaluating the effects of therapeutic procedures.

When the allergy is suspected to be caused by foods, the
most reliable procedure consists of the food elimination
and provocation test. This procedure consists of eliminating
the suspected foods (partial diet elimination) or sometimes all
the foods except glucose, salt and water (complete diet
elimination) for 2 days to see if the symptoms of the allergic
disease disappear or reduce by at least 50%. If the patient
improves during these two days, the eliminated foods are re­
introduced one by one perday to find out which of these foods
would lead to recurrence of the symptoms. In case there is
no improvement even on complete diet elimination, one can
conclude that the allergic symptoms are not being caused by
any of the foods. This procedure may be time-consuming but
if carried out accurately it is very dependable for finding out
if the allergy is caused by a food.

Patients having allergy to a pollen often get their symptoms
only during a fixed period of the year and recover completely
or improve significantly when that period is over. They may
also recover if they move to another place where that plant
does not occur. Inhalant allergy can also be caused by dust
in the house, offices, liberaries and road-side/ Such
patients
derive significant benefit if they prevent the
inhalation of pollen/dust by wearing nasal filters designed by
us. These filters are worn inside the nostrils and are thus not
vol in No. 4 —

ABSTRACTS

St. John's Medical College Journal of Medicine
visible from outside (like contact lenses). Soft nasal filters are
available in 9 different sizes so that the patient can pick the
size which fits his/her nostril,and a week’s training under the
care of the expert is enough to make the patient understand
the mode of its proper usage. There are patients now who
have used these filters for more than 10 years and derived
adequate benefit without any long side effects.
Contact dermatitis is a special type of a reaction in which the
dermatitis is caused by an agent coming in contact with the
surface of the skin. The causative agents generally include
cosmatics, wearing apparel, jewellry, tropically applied
medicines or other agents to which an individual gets
exposed during his daily activities. The areas of the body
involved by the dermatitis generally involve the causative
agents. To facilitate this test we have preapered ready­
made materials in the form of antigen-impregnated discs
and antigen-containing saucers which make the procedure
far easier and quicker. We have also established a
procedure by which the degree of contact hypersensitivity
to a particular antigen in a patient can be determined in the
same way as the levels of antibodies in antibody- mediated
diseases.

Cutaneous reactions to drugs are another important field
because some of the drug
reactions especially
anaphylaxis, toxic epidermal necrolysis (TEN) and StevensJohnson syndrome (SJS) can be rapidly fatal. The
aetiopathogenesis of anaphylactic reactions to penicillin and
their management are well known, but TEN and SJS are still
reported to be highly fatal. We have developed a treatment
schedule with which the fatalities can be prevented almost
completely. This schedule is based on, (1) withdrawing all the
drugs being given to the patient at the time of the drug
reaction,
(2) using an adequate dose of systemic
corticosteroids to control the reaction within 24 hours and
(3) rapidly withdrawing the corticosteriods after the drug
reaction has been controlled.
Another disease in which we have achieved remarkable
success is pemphigus. This is an autoimmune disease
in which IgG autoantobodies circulate in the blood and react
with a protein covering the epidermal cells to produce
blisters all over the skin and mucous membranes. The
disease is potentially fatal in almost all patients within a few
years. By using an arbitrarily designed schedule called
dexamethasone cyclophosphamide plus (DCP) therapy
consicting of 100 mg dexamethasone on 3 consecutive days
along with 500 mg cyclophosphamide on 1 day, repeated at
4 weeks intervals and 50 mg cyclophosphamide orally daily
in between the DCP, we have been able to induce permanent
remissions in almost every patient under our care.

ALLERGIC RHINITS
Allergic Rhinitis has been defined as, an IgE mediated
hypersensitivity disease of the mucous membranes of the
nasal airways characterized by sneezing, nasal blockage,
and discharge. However, classical IgE mediated allergic
rhinitis is not always seen. This is because many allergens
induce not only IgE, but also a complex array of
inflammatory mediators. Also, both Allergy and Infection
both may coexist, each potentiating the other. Consequently
there are two different classifications of RHINITIS.
Infectious and non infectious (Allergic and non allergic)
Allergic further subdivided into Seasonal & Perennial
II) As£eing due to mechanical, allergic, mucociliary clearence abnormality, granulomatous disease, autonomic
imbalance, hormonal imbalance and iatrogenic causes.
I)

It should be borne in mind that the lining of the nose and the
paranasal sinuses is continuous and inflammation of one
invariably affects the other. Also the upper and lower
respiratory tracts are closely related, in anatomy, in
physiological functions and in responses to the environment.

The
incomplete nature of our knowledge of
its
pathophysiology, the plethora of investigations, and
unpredictable nature of response to therapy, makes
formulation of a scientific approach to the management of
these patients difficult.
Dr. Ravi ,C. Nayar
Department of Otorhinolaryngology
St. John’s Medical College and Hospital

Bangalore 560 034

OCULAR ALLERGY
Ocular allergic disorders are among the most commonly
encountered eye problems. Conjunctiva is the most
frequently affected. Ocular allergy and conjunctivitis are
often considered synonymous. Allergic conjunctivitis may
manifest as seasonal allergic conjunctivitis, perennial
allergic
conjuntivittis,
vernal conjunctivitis and gaint
papillary conjunctivitis.
Phlyctenular conjunctivitis
is
considered as a manifestation of endogenous allergy.
Among the deeper inflammations uveitis has a presumed
immunological basis. Transparent structures like cornea, lens
and vireous being avascular, are not frequently involved in
allergic disorders.
Dr. Mahabaleswar MD, DO, MNAMS
Professor and Head
Dept of opthalmology

Dr. J S. Pasricha MD, PhD
Professor of Dermatology
AllMS
New Delhi

December 1990

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St. John's Medical College Journal of Medicine

ABSTRACTS

IN VIVO AND IN VITRO METHODS FOR
THE DIAGNOSIS OF ALLERGY
Antibodies are generally viewed as desirable agents
endowing protection against infectious diseases. However,
immunologic injury mediated by undesirable or harmful
properties of antibodies can lead to hypersensitivity resulting
in tissue damaging reactions. Among the four types of
hypersensitivity, type I is mediated by IgE class of antibodies
resulting in the manifestation of atopic allergy, the clinical
consequence of which may range from bronchial asthama,
allergic rhinitis, allergic conjunctivitis, gastrointestinal allergy,
sytemic anaphylaxis to atopic dermatitis.
The methods currently available for the diagnosis of atopic
allergy can be categorised into three tyeps, viz. (1) skin tests
(prick and intradermal) (2) provacation tests (nasal, bronchial
or conjuctivial challenge with the offending allergen or oral
challenge for foods) and (3) in vivo tests for the quantitation
of total and allergen-specific IgE antibodies.

Elevated levels of IgE antibodies are often associated with
atopic allergy and an in vitro test for total IgE is an useful
indicator in the diagnosis. Positive skin tests together with the
demonstration of specific IgE antibodies in the serum of an
individual will aid in the Identification of the offending
allergens.

IgE antibodies specific foran allergen can be demonstrated by
radioallergosorbent test (RAST) or ELISA or by quatitating the
release of histamine by passively sensitized normal
leucocytes after incubating with atopic patient’s serum and
subsequent challenge with the offending allergen. A
combination of the in vivo and in vitro methods are crucial not
only for determining the atopic status of an individual, but also
to accurately identify the offending allergen(s) which will help
in effective disease management and immunotherapy. The
various in vivo and in vitro methods currently available for the
diagnosis of atopic allergy will be discussed.

'

104

Dr. P.V. Subba Rao
Laboratory of Immunology and
Allergic Diseases,
Department of Biochemistry
Indian Institute of Science
Bangalore -12

VOL in No. 4-----

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St. John's Medical College Journal of Medicine

FOOD ALLERGY
P.S. KAMATH

Food allergy is a diagnosis often entertained, seldom
investigated and rarely confirmed. Food allergy is defined as
an immunologically
medicated clinical syndrome that
develops after ingestion of a dietry product. The definition
thus must fulfill two criteria : (1) The demonstration of a
reproducible reaction to a specific food and (2) evidence
that this reaction is immunologically medicated.

DEFINITIONS
There is so much confusion regarding terminology to be used.
The following is a list of definitions which are used for
uniformity:

PATHOPHYSIOLOGY
The intestinal mucosal barrier protects against dietary
antigen. Disruption of this barrier as in the newborn period or
after an intestinal infection can lead to the development of
food allergy. The integrity
of the mucosal barrier is
contributed to by both immunologic and non immunologic
factors. These factors are outlined in Tablet, and include
pH, peristalsis, proteolytic activity and intestinal epithelial
membrane factors as non immunologic factors; the
immunologic comopnents comprise the gut associated
lymphoid tissue. Factors which increase macromolecular
absorbtion by the gut are listed in Table 2.

Food sensitivity

Adverse immunological response to
ingested food.

Table 1: Factors controlling Macromolelcular Transport
in the Gut

Food allergy

Synonymous with food sensitivity.

Non immunologic Factors

Food anaphylaxis :

Acute food sensitivity involving IgE
antibody.

Food intolerance :

Synonymous with food poisoning.
Indicates non-immunologic action of
ingested food or food additives either
as contaminants or released by
organisms which are contaminants of
food.

Anaphylactoid

Nonimmunologic release of chemical
mediators Reaction mimicing food
anaphylaxis.

Pseudoallergy

Encompass anaphylactoid reaction
as well ass adverse pharmacological
and adverse metaboric reactions.

EPIDEMIOLOGY

Food allergy is reported to occur in upto 7 percent of the
pediatric population. Immaturity is an important factor in the
pathogenesis of the condition and a family history is a major
predisposing factor. Breast feeding during the first few
months of life probably decreases the infant’s risk for the
development of food allergy.

P.S. KAMATH MD, DM
PROFESSOR AND HEAD
DEPARTMENT OF GASTROENTROLOGY
ST JOHNS MEDICAL COLLEGE HOSPITAL
BANGALORE 560 034

December 1990

Indigenous intestinal flora
Secretions
Gastric barrier
Peristaltic movement
Liver filtration
Miscellaneous
Pancreatic snzymes
Goblet cell mucus
Local immunologic defenses
Secretory IgA
Cell-mediated immunity
Other immunoglobulins (lgG,M,E).

Table 2
Factors leading to Enhanced macromoleculte uptake in
Gut

Local antibody deficiency
Secretory IgA deficiency
Altered mucosal barrier
Changes in surface membrance
charge Inflammation
Ulceration
Lysosomal dysfunction
? Storage diseases
? Corticosteroids
Intraluminal factors
Decreased gastric acidity
Pancreatic insufficien
The mechanism of intestinal production of committed B cells
is not completely understood. Lymphocytes within Peyer’s
patches are stimulated by intestinal antigens by means of

105—

St. John's Medical College Journal of Medicine
specialized epithelial cells.
Lymphoblasts migrate to
mesenteric nodes for further maturation, enter the systemic
circulation, and then migrate back to the lamina propria. Here
they produce secretory IgA in response to intestinally
absorbed antigens. While helper T cells mediate a local
intestinal B-cell response, the systemic immune response
to dietary antigen is in general subded or absent. This is
because while the local IgA response is stimulated by local
antigens the IgG and IgE responses are suppressed. This
suppressed response to dietary antigen is called oral
tolerance. Tolerance is mediated by suppressor T cells which
are activated in Peyer’s patches in response to antigen
presentation. Once induced, these suppressor T cells
migrate to pheripheral lymphoid tissue where they mediate
tolerance bysupressing systemic humoral (IgG, IgE, IgM)
and cell-mediated responses to specific dietary antigens.
In the newborn the intestinal mucosal barrier is immature.
The impaired barrier which facilitates macromolecular
uptake is contributed to by changes in the composition of the
microvillous membrane low gastric acid output, decreased
proteolytic activity and altered mucin production. The
intestinal immune mechanisms are also poorly developed
and the newborn intestine lacks the capacity to produce
immunoglobulins. IgA concentrations in saliva, stool and
serum of neonates are lower than in adults.
CLINICAL FEATURES

The clincial features of food allergy are influenced by factors
such as age, the quantity and quality of food ingested and the
presence of coexisting medical conditions.

Two general types of food sensitivity
reactions are
encountered. Immediate and intermediate reaction which are
IgE - mediated and delayed responses which are non-lgEmediated. The immediate or anaphylactic reactions present
as urticaria, laryngeal edema, asphyxia and sometimes
death. The intermediate reactions occur within two hours of
antigen exposure, are less dangerous than immediate
reactions and present with gastrointestinal symproms,
urticaria, asthma and rhiunitis. Delayed reactions which are
non-lgE-mediated occur more than two hours after antigen
exposure, are difficult to diagnose and produce symptoms as
non-specific
and migraine. Other features are recurrent
abdominal pain, joint pains and apthous ulcers. The
symptoms
are
either gastrointestinal or extra
gastrointestinal.
GASTROINTESTINAL TRACT

The oropharynx is the site of initial exposure of food antigen.
Thus, edema and pruritis of the lips, mouth and hypopharynx
may be the initial symptoms of food allergy. Because of
repeated episodes of swelling of the mouth, lips and tongue
chronic mucosal fissuring of the mouth’ may occur.

With

the passage of the antigen into the stomach and

106

intestine a acute onset of nausea, vomiting, abdominal pain,
diarrhea or even bloody diarrhea may occur. At upper
gastrointestinal endoscopy gastric edema and petechial
hemorrhages may be seen.
The pathologic changes in the intestine in children with allergy
to cow’s milk have been well characterized. The mucosa is
thin with patchy areas of villous atrophy. Because of this
mucosal injury infants have diarrhea,
protein-losing
enteropathy, iron deficiency anemia due to chronic intestinal
blood loss and weight loss. Cow’s milk allergy is an important
cause of failure to thrive in infancy.

In children youngerthan 2 years of age proctocolitis can result
from cow’s milk allergy. The primary manifestation is bloody
diarrhea. Sigmoidoscopy and biopsy reveal a focal or*
diffuse colitis with eosinophilic infiltrate. Of interest, this
condition can occur in strictly breast-fed infants. In these
infants the allergic colitis results from maternally derived
cow’s milk protein antigens that are transmitted to the infant
in breast milk. Elimination of cow’s milk from the mother’s diet
results in resolution of symptoms.
Eosinphilic gastroenteritis. The relationship of this condition
to food allergy is not clear. Many areas of the gastrointestinaL
tract are inflamed and diffusely infiltrated with esinophils,
particularity in the gastric antrum. Thickening of the intestinal
wall may occur resulting in bowel obstruction. Serosal
disease results in eosinophilic ascitis. The mucosal form
may be triggered by specific food antigens.

RESPIRATORY TRACT
Rhinorrhea and sneezing are manifestations of food allergy
which may occur in association with gastrointestinal or
cutaneous symptoms. Bronchoconstruction may also occur.
An unusual syndrome has been described in infants fed on
cow’s milk and is characterised by recurrent pneumonia,
pulmonary hemosidserosis, anemia, failure to thrive and
gastrointestinal blood loss. IgE rather than IgE has been
implicated.

Skin. Urticaria and angioedema are frequenct manifestations
of food allergy. In infants food sensitivity is considered to play
a pathogenic role in atopic dermatitis. Characteristic features
are an erythematous maculopapular eruption most often
involving the head and neck, the cheeks and creases behind
the ear. A family history of atopy exists in most cases’.
Positive skin and radioallergosorbent tests to food products
are frequently found.
DIAGNOSIS: The definitive diagnosis for food allergy is
based on the demonstration of a clinical reaction to a food
challenge, with elimination of the symptom complex on
rejnoval of the offending food product. Thus, the criteria for
diagnosis of milk allergy are : 1. Symptoms subside on
eilimination of milk from the diet. 2. Symptoms recur within 48
hours after refeeding. 3. Three sequential challenges are
vol in No. 4 —

St. John's Medical College Journal of Medicine
positive. 4. Symptoms abte after each challenge. While the
criteria seem straigh-forward they are often difficult to satisfy.

The initial approach to the patient with a suspected food
allergy should include a careful history and physical
examination. The important questions to be asked should
relate to the severity of the food reaction, the timing of the
reaction after ingestion of food, the type of foods involved,
and a family history. It is known that patient’s histories are
often unreliable. In such cases an elimination diet may be
useful for diagnosing untoward reactions to food.

Skin tests with food extracts are performed by the prick or
scratch method. A positive skin test is defined as a wheal with
a diameter of 3 mm or greater than that produced in a
negative control test. Fasle positives are common; a
negative test ususally indicates absence of allergy to the food
product. Skin tests are unreliable in children younger than 3
years of age. The radioallergosorbent test is more expensive
but not superior to skin testing.

population especially, adequate calorie, vitamin and mineral
replacement must be ensured. About 30 to 40% of children
lose their sensitivity to some foods after several years.
Antohistaminics may be useful for the control of rhinitis or
urticaria. The ideal approach, of course, is to prevent the
development of food allergy.
SUGGESTED READING:
1. Heyman MB. Food sensitivity and eosinophilic gastroenteropathies.
In Gastrointestinal Disease: Pathophysiology Diagnosis
Management
Sleisenger MH, FordtranJS Eds. Fourth Edition, Philadelphia WBSaunders
1989; 1113-34.
2. Schreiber RA, Walker WA. Food allergy. Facts and fiction. Mayo Clin Proc
1989;64:1381-91.
3. Walker WA. Antigen handling by the smal intestine. Clin Gastroenterol
1986;15:1-20
4. Walker Smith JA: Food sensitive enteropathies. Clin Gastroenterol
1986;15:55-6.

TREATMENT

5. Stem M, Walker WA. Foody allergy and intolerance. Pediatr Clin North Am
1985;32:471-84.

The only proven effective therapy is an elimination diet. It is
important
to avoid malnutirition and in the pediatric

6. Alpers DH, Clouse RE, Stenson WF. Manual of Nutritional therapeutics
2nd Ed. Boston, Little Brown and Co. 1988.

— December 1990

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St. John's Medical College Journal of Medicine

PRACTICAL SKIN TEST, PROCEDURES IN ALLERGY
I- PATCH TESTING
ANIL ABRAHAM
THE PRINCIPLES OF PATCH TESTING

SITE FOR PATCH TEST

INTRODUCTION

a)

Patch testing is based on the principle that in an allergic
individual, the whole skin is capable of reacting with the
causative allergen. Therefore if the antigen is applied on an
apparently
normal skin area, it could provoke
a
representative reaction on the area tested.

Upper back is the best site; lower back, flexor aspects of
arm and forearm and extensor aspect of thigh are
alternatives.

PATCH TEST UNITS:

Several patch test units have been used. The more popular
ones have been listed :

a) Al-test unit
b) Finn chamber
c) Duhring chamber
d) Pasricha patch test unit
e) Indigenous Finn chamber (Kaur & Sharma)
f) Pre-packed units (PA patch)

The simplest patch test unit which can be implemented with
minimum materials is described in Fig.1.
Allergen

2.5 Cm2 Gauze

Avoid mobile areas such as over the spine or the medial
border of the scapula (Fig.2).
c) Avoid areas with active dermatitis.
d) Avoid hirsute parts of the body
b)

TIMING OF PATCH TEST

a)
b)

Preferably after active dermatitis has settled.
To be avoided when the patient is on systemic steroids
or other immunosuppressive drugs. (Not > 20 mg
Prednisolone).

EQUIPMENT AT HAND DURING TESTING

Fig. 1 : Patch Test Unit

a) Patch test kit
b) Allergens in appropriate vehicle and concentration
c) Marker pen.
PRACTICAL STEPS IN PATCH TESTING

DR. ANIL ABRAHAM

MD, DNB

DEPT. OF DERMATOLOGY,
ST.JOHN’S MEDICAL COLLEGE HOSPITAL
BANGALORE 560 034
108

a)
b)
c)
d)
e)

Detailed history for possible allergens.
Review treatment history
Examine back for suitability for patch testing
Clean area for proposed patch
Transfer allergens to patch test unit
VOL HI No. 4-----

St. John’s Medical College Journal of Medicine
f) Record and number allergens on proforma
g) Transfer patch test unit to patient’s back. (Fig ?).

INSTRUCTIONS TO PATIENT
a)
b)
c)
d)
e)

Do not bathe/indulge in strenuous activity for 48 hours.
Report for reading after 48 hours.
If there is severe itching, report to the doctor early.
Do not ingest/apply medication during this period
Do not remove patch for 48 hours.

READINGS OF RESULTS
?
Doubtful reaction
+ Weak (Non-vesicular)
++ Strong (vesicular)
+++ Extreme
Negative
IR Irritant reaction
NT Note tested

Faint Macular Erythema only
Erythema, Infiltrn, Papules
Above + vesicles
Bullous reaction
Nothing to see
Well demarcated, severe

MODIFICATIONS OF PATCH TESTING

a)

b)

Photopatch test: Where the sun may play a contributory
role the patch test is modified to include sun exposure of
a duplicate set of allergens.
Usage test: This is common practice in the case of hair­
dyes and perfumes and consists of direct non-occlusive
application of the suspected offender.

FALSE POSITIVE PATCH TEST RESULTS

a) Concentrated/lrritant Test substance
b) Active dermatitis
c) Angry-Back Syndrome
d) Plaster reaction
FALSE NEGATIVE PATCH TEST RESULTS

a) Incorrect diluent/weak test substance
b) On topical or high dose systemic steroids
c) Poor occlusion of Patch
d) Reading too early/too late

RELEVANCE OF PATCH TESTING
Calnan states that the greatest abuse of the patch test is
failure to use this test! it is a unique direct in-vivo test, and
when properly applied and correctly interpreted it is the only
scientific proof of contact allergic dermatitis. A good history
and appropriate clinical correlation with environmental
allergens are invaluable in optimally utilizing the Patch Test in
allergic skin disease.

RECOMMENDED READING
1. Calnan CD: The use and abuse of Patch Tests' In HI Maibach and GA
Gellin (eds): Occupational and Industrial Dermatology, Chicago, Yr. BK.
Medical Publishers 1982 p35.
2. Arndt KA : ‘Patch Testing* in Manual of Dermatologic Therapeutics.
Boston, Little Brown & Co. 1989 p 184.

COMPLICATIONS OF PATCH TESTING

3. Fischer AA: The Role of Patch Testing in Contact Derm. Philadelphia,
Lea & Febiger, 1986 pp9-29.

a)
b)

4. Pasricha JS: ‘Testing Procedures' In contact Dermatitis in India. Survey
of the causes of contact Dermatitis in India. 1988;1:6-20.

Sensitization to new allergens
Rarely, flare of dermatitis, secondary infection pigmenta­
tion, scars, keloids.

December 1990

109—

DERMATOLOGY- SYMPOSIUM

St. John's Medical College Journal of Medicine

PRACTICAL PROCEDURES IN SKIN TESTS FOR ALLERGY
II - PRICK TESTING
ELIZABETH JAYASEELAN, S.C. RAJENDRAN, ANIL ABRAHAM

INTRODUCTION

EQUIPMENT AT HAND DURING PRICK TESTING

Skin tests are the fundamental tools in the investigation of IgE
mediated allergic diseases. The origin of these tests can be
traced back to Harrison Blackley in the 1860’s who first
attempted scarification for the diagnosis of Hay Fever. The
procedure was improved and made more scientific by Noon
and Freeman in 1911.

a) Allergen Extracts : A standard extract is defined as one
which contains a measured amount of specific antigen. Most
of the presently available commercial extrats have labels that
specify the volume of protein nitrogen units (PNU) or state
the weight to volume ratio of the extracted ingredients.
Squeezed juice, beer, wine or milk can be safely used for skin
testing.

PATHOGENIC BASIS

The antigen in the extract used reacts with the specific IgE
antibodies fixed to the most cells of the skin, triggering off their
degranulation. In those who have never been exposed to the
allergen, orthose who have not developed IgE to the provoca­
tive extract, the reaction will be negative.

b) Controls : Skin testing employs a negative control in the
form of saline or diluent and a positive control, 0.1 mg/ml
histamine hydrochloride. The positive control is the standard
against which positivity is graded and is also useful in detect­
ing suppression of the test reponse by medication.
FACTORS INFLUENCING TEST RESULTS

Similarly following immunotherapy by desensitisation, block­
ing antibodies or IgG will bind to the antigen, thus impending
an IgE moderated most cell response.
Types of skin tests :

There are two approaches to allergy skin testing
A. Cutaneous or Epicutaneous
a) Scratch test
b) Puncture test
c) Prick test
B. Intradermal
- In this method the extract is injected into the superficial
layers of the dermis.

COMPARITIVE ADVANTAGES OF THE PRICK TEST
The Present discussion concentrates on the prick
method because of it's relative advantages.
a) Safety, speed and simplicity
b) Numerous antigens can be tested simultaneously
c) Negligible risk of anaphylaxis
d) Minimum discomfort
DR. ELIZABETH JAYASEELAN
DR. S.C. RAJENDRAN M.D
DR. ANIL ABRAHAM M.D

test

DNB

DEPARTMENT OF DERMATOLOGY
ST.JOHN'S MEDICAL COLLEGE HOSPITAL
BANGALORE
COMMUNITY WEALTH

a) Medication
Antihistamines affect the degree and duration of suppresion
of wheals induced by prick testing with histamine.
The mean suppression following diphenhydramine was 1.9
days, chlorpheniramine 2.5 days, hydroxyzine 4.3 days, terfenadine 6 days and aztemizole 27 days. Anti-emetics and
tranquilizers of phenothiazine and imipramine class also have
antihistaminic activity. Hence routine antihistaminic drugs
should be discontinued for a week before skin tests and longer
acting drugs like astemizole should be stopped at least two
and a half weeks before. The positive control with histamine
during skin testing therefore, has an important role to play in
determining whetherdrugs have du lied the allergic response.

Bronchodialators like epinephrine, theophylline and beta-2
specific adrenergic agonists do not interfere with the skin
reaction and can be continued safely. Corticosteroids upto an
equivalent of 30 mg prednisolone daily have also been
considered admissable.

b) Site of testing
The most reactive parts are the upper and mid-back and these
sites have the additional advantage of furnishing a wide area
to test a large number of allergens simultaneously.
The forearm is commonly chosen for convenience and at this
site the ulnar border is most reactive while the wrist is the least
reactive.

c) Timing of Testing
CE^ghy morning is the least reactive time of the day while the

V Main, I Block
______________________________ ^Qramonanl^____________

Bangalore-560034
India

VOL III No. 4 —

St. John's Medical College Journal of Medicine
period between 1900 hours and 2300 hours has been found
to elicit the maximum response.

d) Age of the Patient
The reaction in infants is smaller than in adults and the
maximum response has been elicited in individuals in the third
decade. There is a steady decline in responsiveness after the
age of fifty which possibly corresponds to a decrease in total
and specific IgE levels with age.
PRACTICAL STEPS IN PRICK TESTING
1. Historical review for possible allergens.
2. Advice regarding prior discontinuation of medication that
may interfere with result.
3. Test site cleaned with spirit and allergen sites marked.
4. Allergen extracts placed as drops near the marked sites
with at least 4 cms. distance between adjacent allergens.
5. Positive control (saline) also positioned.
6. Standard lancet used at 45° angle to cause a small break
in the epidermis without bleeding at the site of extract. Saline
is pricked first and histamine last. The same lancet is used
throughout the test by wiping the tip with a moist gauze after
each allergen.
7. Extracts are mopped with filter paper.
8. Readings are carried out at 10 minutes, 15 minutes and 20
minutes.
9. Equipment is at hand to deal with a severe reaction.

CONCLUSION

The prick test is a safe, sensitive and economical means of
obtaining information regarding allergy, upon which a clinical
judgement can be based.

GRADING OF RESULTS

Grading depends on the size of the wheal in relation to the
wheal produced by the positive control 0.1 mgm/ml histamine
hydrochloride the measurement usually used is the average
of the longest diameter, and the diameter perpendicular to it.
Unfortunately there are several methods of grading the
response, the Scandinavian society of allergologists have
proposed an acceptable grading which is implemented at the
allergy clinic of St. John’s Medical College Hospital.

Grade

4+
3+
2+

Description
Wheal twice the size of positive
control / or pseudopods
Wheal equal to the size of positive
control
Wheal half the size of positive control

Positive control
Negative control
Negative result

: Histamine
: Saline
: less than 2 +

FALSE NEGATIVE TESTS

FALSE POSITIVE RESULTS
1. Lack of stability or deterioration of stored extract.
2. Localized allergy is a phenomenon where skin tests may
be negative because the allergic response is only at the
trigger anatomic site eg. the nose or bronchus.
3. Skin sensitivity in children may be delayed by 1-2 years
after onset of symptoms.

1. Concentrated extract
2. Inadequate distance between extracts : - If 4-5 cms
distance is not maintained, a strong positive can cause non­
specific enhancement of neighbouring tests.
3. Histamine control too close to allergens

RELEVANCE OF THE PRICK TEST

RECOMMENDED READING

1. The test correlates well with clinical disease and can be
performed rapidly and safely.
2. It can be used to test a large number of suspected
allergens simultaneously.
3. There is a good correlation between a positive prick test
and a positive RAST.
4. The test is useful as an indicator of the response to
immunotherapy by hyposensitisation.
5. However the skin test MUST be correlated with the
patient’s history and environmental exposure. Irrelevant
positives to unrelated food or environmental allergens can be
totally misleading for the unwary practiconer.
6. In addition discontinuing antihistaminics in patients with
active disease may be a hurdle in practice. So also allergy skin
tests without relevant advice on how to avoid the allergent,
and without desensitisation facilities would be a farce.

December 1990

1. Diagnostic Procedures in allergy - Allergy skin testing : Harold S. Nelson
Annals of Allergy 1983 Pg. 411-416

2. Allergy skin testing : Imber We, Journal of Allergy and Clinical Immunol­
ogy 1977;60:47.

3. Immediate (IgE mediated) skin testing in diagnosis of allergic disease.
Annals of Allergy 1978;41:211.
4. Skin test reactivity and clinical allergen sensitivity in infancy : p.p
Asperen Journal of Allergy and clinical Immunology 1984;73:381-382.
5. Duration of inhibition of skin reactivity by antihistamines: Annals of Allergy
1989 vol.62:525.

6. Clinical evaluation of a new Enzyme*- Assay for allergen - specific IgE.
Joel Du etal Annals of Allergy. 1989;Vol.62:503.
7. Is the choice of allergy skin testing versus in vitro determination of specific
IgE, no longer a scientific issue? Annals of Allergy 198962:373.

111—

REVIEW

St. John's Medical College Journal of Medicine

AUTOLOGUS BLOOD TRANSFUSION : ITS ROLE IN
ORAL & MAXILLOFACIAL SURGERY
P.K.NAYAK, K.S.LIM, R.P. WARD-BOOTH

Oral cancer in the U.K. represents about 2% of all cancers.
In India this figure is elevated to about 30% of all cancers.
Many patients present too late for any effective treatment.
Others suitable for treatment receive radiotherapy. This
leaves a substantial number of patients with oral cancer
who require surgery as a primary modality or as salvage after
radiotherapy. This latter group may have their surgery antici­
pated as part of a planned combined treatment. These
patients therefore present a significant surgical problem to
maxillofacial surgeons.
The highly vascular anatomy of the head and neck region
makes it necessary to cross-match and often transfuse blood
to patients undergoing this type of surgery. Although it is
not always necessary to undertake the extensive recon­
structive procedures seen in western maxillofacial surgery,
the ablative surgery normally requires the patient to be
cross-matched.

Maintenance of well stocked blood banks is a problem in
any country, but is considerably more difficult in the third
world countries. Many patients are concerned, albeit errone­
ously, that blood transfusion may be associated with the
risk of cross-infection, particularly from A.I.D.S. (Acquired
Immune Deficiency Syndrome).
It has been proposed1 that autologous blood transfusion the recycling of the patient’s own blood, this being pre­
deposited during the days/weeks that precede the operation
- may alleviate these fears. It will also have other benefits
which are probably more significant. The development of
an effective blood substitute has not yet materialised.

P.K. NAYAK, MDS, FDS,RCS (ENG), FDS, RCPS
(GLAS), FFD, RCS(IRE)

DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY
CENTRAL MIDDLESEX HOSPITAL
LONDON. 10 7NS
K.S. UM, BDS, LDS, RCS (ENG)
R.P. WARD - BOOTH, MBCHB, FDS, RCS (ENG),
FRCS (ED),

CONSULTANT ORAL & MAXILLOFACIAL SURGEON
SUDERLAND DISTRICT GENERAL HOSPITAL
KAYLL ROAD SUNDERLAND. SR4 7T0
112

Autologous blood transfusion (ABT) eliminates virtually all
the hazards of homologous blood transfusion. Cross­
matching is not essential, no disease is transmitted, the
presence of drugs is less important and the risk of isoimmu­
nization to foreign proteins present in donor blood is ex­
cluded. Patients with religious objections to blood
transfusions may accept ABT with certain safeguards. It must
be stressed, however, that the risk of transmission of the
H.I.V. is very low, estimated at less than one in a million.2
TECHNIQUE OF AUTOLOGOUS BLOOD
TRANSFUSION

The technique of ABT is well established in the United States
and Australia 3-4-5. Increasing sophistication of surgery indi­
cates that the need for blood has reached a stage when
demand is in the danger of out-stripping supply. Most forms
of elective surgery may be covered by pre-operative
donation, and may orthopaedic, vascular and gynaecologi­
cal procedures can be carried out using autologous blood.
Results show that about 25% require no blood at all, and in
two third of the operations, autologous blood sufficed6-7.
There are threee methods for collecting blood for ABT:
1. Salvage of blood during and after cardiopulmonary
bypass surgery. Blood scavenging
machines8*9 are not
widely used in the U.K. but can be helpful for patients with
ruptured aortic (thoracoabdominal) aneurysm, ectopic
pregnancy, liver transplantation and trauma.

2. Peri-operative collection and haemodilution in theatre
provides a ready supply of fresh blood for retransfusion at
completion of surgery.

3. Pre-operative donation and storage10-11 is cheap, effec­
tive and provides economy of homologous blood usage.
This is the method to be discussed in this paper. In the U.K.
the blood transfusion service does not recognise the
particular need for ABT, and therefore it is not routinely
available. In Sunderland, however, whilst there is no routine
service provided a limited number of patients are able to
receive ABT on an experimental basis. This service has
been extended to provide a regular supply.

ABT needs careful and separate identification of blood for
autologous use. Clearly, the blood will not be screened and
cross matched in the conventional manner of homologous
transfusion, and hence it must be strictly segretated from
normal blood bank sources. There are no definite limits as to
VOL HI No. 4—

St. John's Medical College Journal of Medicine
the age at which the blood can be collected from the donor,
but children would
normally be unco-operative. It is
suggested that anyone who has normal marrow function and
who is fit for general anaesthesia and surgery, is fit to donate
blood in an ABT program12. A patient who is medically eligible
for ABT must be fully informed of the risks and requirements
of the procedure and should sign a specified consent form
for this purpose.
The patient must present with a haemoglobin greater than
11 gms/dl, or a packed cell volume of 34% or more. In addition,
no more than 12% of the estimated blood volume of a patient
should be drawn at any one visit. The autologous blood is
available for approximately 35 days after collection with the
blood stored in the liquid form with citrate phosphate dextrose
and adenine. Upto 8 units of blood (405-495 mis. each) can
be withdrawn altogether. In the experience of oral surgeons
in the United States11 a predeposit of 2 units was required in
most of their cases of combined maxillary and mandibular
orthognathic surgery.
The blood should be collected at no more than 3 day intervals
and last phlebotomy should take place no less than 72 hours
before surgery. 72 hours is the maximum time required for
mobilisation of protein to return the plasma volume to
normal. Iron availability is the limiting factor in haematopoiesis
following phlebotomy, and chronic phlebotomy of one unit
every two days is well tolerated as long as adequate iron
replacement is available. Ferrous sulphate (300 mgs 3 times
daily) is prescribed and increased marrow activity achieves
an increase in haemoglobin concentration of 1 gm/dl, replacing
one unit every 3 to 5 days.

Under such management the patient should have at opera­
tion, a haemoglobin above 10 gm/dl, a level considered safe
by the majority of anaesthetists. The drop in packed cell
volume following the operation may have the following advan­
tages.
1.
2.
3.

Reduced possibility of thrombosis
Improved capillary perfusion
Reduced whole blood viscosity

Additionally, the marrow is maximally active at the time of
operation and is better able to replace any blood loss above
that provided by autologous transfusion.

Remaining blood may, if necessary, be returned to the blood
bank and subsequently used for homologous transfusion. If
transfusion of autologous units does not occur within the
dating period of the oldest unit, loss of this unit may be
prevented by returning this blood to the donor just after
draining a fresh unit - the ‘leap frogging’ technique.
DISCUSSION

Autologous blood transfusion is a technique popularised in
the west for essentially healthy, well nourished patients under­
December 1990

going elective surgery. Transporting this technique to
India, despite all its potential advantages requires careful
consideration.

In India maxillofacial surgery rarely involves the elective
surgery seen in the U.K. For example, facial osteotomies
are rarely carried out, although large jaw cysts, benign
salivary lesions will present. Naturally it is estimated that
even in the U.K. patients will have pre-surgical radiotherapy
up to 40 Gy. As mentioned before the reconstructive
surgery is frequently minimal and blood loss correspond­
ingly less. Only two units are normally required for resection
of the tumour and neck dissection.
It thus seems highly likely that the small amount of blood
required for transfusion coupled with the inevitable delays
before the patient will get to surgery make ABT a viable
option. The indications for ABT in the west also apply to
India.
The indications for transfusion of blood products remain
the same, but are not always strictly applied. This may on
occasions lead to excessive transfusions. These indications
are transfusion of packed cells or whole blood to replace
blood loss, and the transfer of specific blood products,
e.g. Facter VII in haemophiliacs.

There are clearly many good reasons for avoiding
unnecessary blood transfusion. The most significant
reason are the immunological factrs19.
Alloimmunisation

Incompatibility

Red cell, leucocyte and platelet
antigens.
Plasma protein antigens

a. Red cell incompatibility
Intravascular haemolysis - ABO
incompatibility
Extravascular haemolysis Immediate/delayed
b. Leucocyte and platelet
incompatibility
Febrile reactions (granulocytes)
Pulmonary reaction (granulocytes)
Post-transfusion purpura (platelets)
Poor survival of transfused
platelets and granulocytes
Graft vs. Host reactions
(lymphocytes)

c.

Plasma protein incompatibility
Urticarial and anaphylactic
reactions.

Post-transfusion hepatitis is a possible sequel of blood
transfusion20, and may becausedby the Hepatitis B virus,

St. John's Medical College Journal of Medicine
agent(s) of Non-A Non-B Hepatitis, Epstein-Bar virus and
Cytomegalovirus. Bacterial Syphilis, Brucellosis, Rickettsial
disease and parasitic (Malaria, Fillariasis, Trypansomiasis,
Leishmaniasis ad toxoplasmosis) infections may also be
transmitted by blood transfusion.
In young, fit and healthy patients, it is quite acceptable for
them to lose 10-30% of their total blood volume during
surgery. If however, blood transfuion is anticipated, then
there are several advantages in offering the patient the
option of ABT. The advantages of ABT are summarised as
follows2’.
1. Blood is available in areas remote from donor banks,
under all conditions with no limitations due to time,
geography or catastrophe.

Therefore in view of the distinct advantages, in terms of
safety and effectiveness, offered by the technique of ABT
as compared to homologous blood transfusion it would seem
particularly relevant to this type of oral and maxillofacial
surgery. The logistics and need to establish this service in
India requires further evaluation.
It must be emphasised however, that any discussion on
the role of ABT does not imply any doubts about the
competence or effectiveness of the screening procedures
by the Blood Transfusion Service. Above all, this paper
aims to stimulate greater consideration to the role of
Autologous Blood Transfusion in third world countries.

REFERENCES
1.

2. In instances of rare blood types, the autologous may be
the only possible donor.

Marciani R.D.J. Oral & Maxfac. Surg. 1985;43:201-204.

2. Barbara J.A.J. Contreras M. and Hewit P. Brit. J. Hosp. Med. 1986;36,3:178184.

3. The possibility of errors in typing or cross-matching are
eliminated.

3. Zuck T. Introduction in: Amerdan Association of Blood Banks, ed. Autolo­
gous transfusion. Washington DC : Amercian Association of Blood Banks
1976.

4. No incompatibility reactions or sensitization to other
human antigens will occur.

4. Ibister J.P. Strategies for avoiding or minimising homologous blood transfu­
sion. A sequel to the AIDS scare. Med. J. AusL 1985;142:596-598.

5. Pyogenic or allergic reactions due to blood factors are
eliminated.

5. American Association of Blood Banks. Standards for blood banks and
transfusion services. Washington, DC: American Association of Blood Banks
1981.

6. There is no risk of exposure to carrier transmitted
diseases.

6. Nicholls M.D. Janu M.R. Davies V.J. and Wedderbrun D.E. Autologous
blood transfusion for elective surgery. Med. J. Aust 1986;144:396-399.

7. Religious priniciples may be respected in instances when
homologous blood is unacceptable.
8. In cases of shock, better volume expansion has been
reported with autologous rather than homologous transfu­
sion.
9. Labile coagulation factors are preserved with immediate
reinfusion.

10.

Erythropoiesis is stimulated by donation at short intervals.

The possible disadvantages are that there is clearly a need
for time to be available prior to surgery for the blood to be
collected. The patient must be relatively fit and well, with no
significant anaemia, coagulopathy or presence of microem­
boli or bacteraemia. In recent years, claims have been made
concerning the effect of homologous blood on the recurrence
of colonic cancer 22-23-24. in terms of cost effectiveness, it
would seem that there is an initial “setting up” cost because
ABT is normally provided at the centres where the oeprations
are to be performed, rather than at centralised transfusion
laboratories. Eventually, the unit cost should fall and be
offset by reduced patient morbidity, and diversion of
unused blood for use by other patients. In addition, individuals
may be recruited into the population of blood donors.
114

7. James S.E. and Smith M.A. Autologous blood banks transfusion In elective
orthopaedic surgery. J. Royal Soc. Med. 1987;80:284-285.
8. Propovsky M.A. Devine P.A. and Taswell H.F. Intraoperative autologous
transfusion. Mayoclin. Proc. 1985;60:125-134.

9. Saarela E. Autotransfusion. A review. Ann. Clin. Res. 1981 ;(suppl 33) :4856.

10. Cable R.G. Implementation of a predonation system. Int Anaesthesiol.
Clin. 1982;20:59-76.
11. Kruskall M.S. Glazer E.E. Leonard S.S. et al. Utiisation and effectiveness
of a hospital autologous preoperative blood donor program. Transfusion
1986;26:335-340.

12. Miles G. Langston H. and Delassandro W. Experience with autotransfu­
sions. Surg. Gynaecol. Obstet. 1982:115:589-694.
13. Kay LA. The need for autologous blood transufion. Brit Med.J.
1987;294:137-139.
14. Ammann A.J. Cowan M.J. Wara D.W. et al. Acquired immunodefidnecy in
an infant: Possible transmission by means of blood products. Lancet
1983;1:956.
15. Curran J.W. Lawrence D.N. Jaffe H.W. et al. AIDS assodated with
transfusions. N.Engl.J.Med 1984;310:69.
16. Peterman T.A. Jaffe H.W. Feorino P.M. et al. Transfusion associated with
AIDS in the United States. J.A.M.A. 1985;254:2913.
17.

Rouzioux C. Chamaret S. Montagnier I. et al. Absence of antibodies AIDS

VOL III No. 4-----

St. John's Medical College Journal of Medicine
virus In haemophiliacs treated with heat treated FACT VIII concentre. Lancet
1985;1:271.

18. Wells M.A, Wittek A.E, Epstein J.S. etal. Inactivation and partition on HTLV
III during ehtanolfractionation of plasma. Transfusion 1986;26210.

19. Walters A.H. and Murphy M.F. Haematology Seminar: Adverse immunol­
ogical reaction to blood transfusion. Hosp. Update 1986;12.7:565-574.
20. Seidl S. and Kuhnl P. Transmission of disease by blood transfusion. World
J. Surg. 1987;11:30-35.
21. Kuban O.J. Autologous blood transfusion in American Association of Blood
Banks. Autologus transfuion - A technical workshop Washington DC. Ameri­
can Association of Blood Banks. 1976;2-25.

22. Burrows and Tartter P. Effects of blood transfuions on colonic malignancy
recurrence rate. Lancet 1982;2:62.

23. Blumberg N, Agarwal M.M. and Chuang C. Relation between recurrence
of cancer of the colon and blood transfusion. Brit. Med. J. 1985.290:10371039.
24. Fielding LP. Red for danger: Blood transfusion and colorectal cancer. Brit
Med. J. 1985;291:841-842.

December 1990
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