© 2004 American Thoracic Society
Severe Asthma Attacks after Sexual IntercourseTo the Editor:A 48-year-old white man was referred to our outpatient clinic with a history of bronchial asthma and rhinorrhea. His illness had begun in May 1987 with watery rhinorrhea and nasal congestion. The skin prick tests with a set of allergens performed at that time were negative. Nasal examination revealed several polyps. Despite two surgical removals of polyps, his nasal symptoms persisted. The first asthma attack occurred in 1996. Exacerbations were taking place 2 to 3 times a week, usually in the early morning. Severe dyspnea required emergency treatment. At the beginning, the patient was treated by his general practitioner with budesonide, salbutamol, cetirizine, oxymetazoline, and theophylline. This treatment was effective and the patient was doing well until several months later when he visited his GP again reporting an asthma exacerbation. He was then referred to our clinic. He described that his asthma exacerbations strictly followed sexual intercourse with his wife. On examination, the chest was clear. Spirometry revealed a 23.08% increase in FEV1 after inhalation of 400 µg of albuterol. As the skin prick test with the most common allergens and measurement of specific IgE (ELISA method) were unrevealing, other mechanisms of bronchoconstriction were analyzed. Taking into consideration the history of recurrent polyposis and asthma, a diagnosis of aspirin hypersensitivity was thought possible. The patient was not taking any nonsteroidal antiinflammatory drugs (NSAIDs) at that time, and no such incident ever happened to him before. It was revealed, however, that his wife suffered from chronic headaches and that she had started to use aspirin as a painkiller. Moreover, the timing of the patient's postcoital asthma exacerbations and his wife's ingestion of aspirin overlapped. He also noticed that his asthma exacerbations never happened when he was using condoms. To verify this suspicion, bronchial provocation test with a lysine aspirin was performed (1). A significant drop in FEV1 was observed 28 minutes after inhalation of a cumulative dose of 30 µg of lysine aspirin (Table 1) . Once the diagnosis was confirmed, the patient was advised to avoid aspirin and other NSAIDs. His wife was advised to switch to paracetamol. Thereafter, their sexual intercourse did not cause asthma attacks in the husband.
Asthmatic attacks precipitated by aspirin occur in about 8–20% of all individuals with asthma. Inhibitory action of NSAIDs on prostaglandin biosynthesis is considered to be one possible explanation of asthma exacerbations in aspirin-intolerant individuals with asthma. Most NSAIDs are potent inhibitors of both cyclooxygenase isoforms: COX-1 and COX-2. In subjects with aspirin hypersensitivity, disruption of the synthesis of prostaglandin E2 and I2 and overproduction of cysteinyl leukotrienes (Cyst-LT) seem to be crucial in the pathogenesis of bronchial symptoms. This original hypothesis by Szczeklik and colleagues (2) found confirmation in several studies. Increased levels of Cyst-LT in nasal washings, bronchoalveolar fluid, and urine after aspirin challenge were found (3, 4). The recently introduced highly selective inhibitors of COX-2 (celecoxib and rofecoxib) are well tolerated by aspirin-intolerant patients. Also several antileukotriene drugs provide good control of symptoms and show a steroid sparing effect in some NSAID-hypersensitive subjects (5). The case we present suggests that asthma exacerbations in NSAID-sensitive individuals with asthma may be precipitated by other means than oral intake of an NSAID itself. Blanca and collegues (6) found two cases of anaphylaxis to penicillins after nontherapeutic exposure; in these cases anaphylaxis developed after sexual intercourse with a partner who was receiving penicillin. Severe anaphylactic manifestations may occur in latex-hypersensitive subjects consequent to condom-protected sexual intercourse (7). Hypersensitivity symptoms, including cough, urticaria, angioedema, dyspnea, and anaphylactic reaction, in a woman immediately after sexual intercourse were described by Tomitaka and coworkers (8). In that case, hypersensitivity to human seminal plasma was diagnosed. Freeman (9) reported a woman who complained of severe itching and flushing after sexual intercourse, and was found to be allergic to human semen. In our patient, a positive aspirin challenge and the clear correlation of his symptoms with his wife's intake of aspirin allowed us to make a diagnosis. If the provocation test with aspirin is negative, the possibility of hypersensitivity to human plasma should be taken into consideration. The presented case may explain some severe asthma attacks in patients with aspirin-induced asthma during the night. Unusual causes of asthma attacks after sexual intercourse include latex allergy occurring during condom-protected intercourse, nontherapeutic exposure to a drug in hypersensitive patients, and semen or human plasma allergy, all of which should be considered in such cases.
Medical University of FOOTNOTES Conflict of Interest Statement: P.K. does not have a financial relationship with a commercial entity that has an interest in the subject of this letter; M.K. does not have a financial relationship with a commercial entity that has an interest in the subject of this letter; M.B.M. does not have a financial relationship with a commercial entity that has an interest in the subject of this letter. REFERENCES
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