A new, faster, and safe nasal provocation test method for diagnosing mite allergic rhinitis

[Immunoglobulin E in nasal secretions]

Diagnosis of allergic disease is primarily verified by IgE blood serum analysis. Determination in nasal secretions is technically more difficult, particularly due to a low specimen volume and the method of sample collection. Nasal secretions are frequently collected by lavage, which allows qualitative diagnostics, whereas swabs with defined amounts of mucus enable quantitative analyses. In the case of negative skin and serum tests, detection of IgE in nasal mucus combined with nasal provocation testing aids differentiation between local allergic and nonallergic rhinitis.

Selection of allergen extract for immunotherapy in polysensitized allergic rhinitis patients

Aim: To evaluate the criteria used by allergists in selecting an immunotherapy extract (allergen immunotherapy [AIT]-extract) in rhinitis patients with polysensitization. Methods: First, a cross-sectional study was carried out by evaluating different factors that influence the medical choice of AIT-extract. Second, a literature review was performed by evaluating the diagnostic performance of atopy tests. Results: A total of 419 patients were included (84 children, 149 adolescents and 186 adults). Anamnesis, atopy tests and exposure to pets were the main factors for choosing the AIT extract. The sensitivity and specificity of atopy tests were high for Dermatophagoides spp., (>80%), moderate for pets (60%) and indeterminate for Blomia tropicalis. Conclusion: NCTs could be necessary for AIT-extract selection in polysensitized allergic rhinitis patients.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Validity of Skin Prick Test to Bermuda Grass in a desert environment

Background and aim:

Skin prick test (SPT) with a wheal diameter of >3 mm, generally accepted as a positive, is most commonly use diagnostic tool for Allergic rhinitis. Aim was to validate wheal size of Skin Prick Test for the Bermuda grass, in desert environment, with positive Bermuda grass Nasal challenge in same environment.

Methods:

In 53 adults, mean age 33.43 ± 9.36 years, both gender (females: 33.96%), SPT positive on Bermuda grass with cut off wheal longest diameter of 3 mm, Bermuda grass nasal challenge test (bgNCT) was carried out. Response was assessed subjectively (scored) and objectively (PNIF). Safety profile was assessed by PEF measurement.

Results:

Mean weal size of SPT (mm) was bigger in bgNCT positive patients (n=47; 88.68%) 8 [4, 15] vs 5 [3, 6] (p<0.0001). ROC analysis showed Bermuda Grass SPT at the threshold of >6.5mm enabled identification of Bermuda challenge with sensitivity of 82.98% and specificity of 100.0% (area under the curve 0.9326, standard error 0.03528; 95% confidence interval (CI): 0.8635 to 1.002; p=0.0006203).

Conclusions:

A SPT wheal size ≥6.5mm might be considered as an appropriate wheal size for confirming Bermuda grass allergy in adults with SAR, avoiding the demanding, time consuming and often unavailable bgNCT, especially in patients eligible for allergen immunotherapy. In these patients, bgNCT is recommended if SPT wheal size is <6.5 mm. (www.actabiomedica.it)

Prevalence, comorbidities, diagnosis, and treatment of nonallergic rhinitis: real-world comparison with allergic rhinitis

Rhinitis is among the most common respiratory diseases in children. Nonallergic rhinitis, which involves nasal symptoms without evidence of systemic allergic inflammation or infection, is a heterogeneous entity with diverse manifestations and intensities. Nonallergic rhinitis accounts for 16%-89% of the chronic rhinitis cases, affecting 1%-50% (median 10%) of the total pediatric population. The clinical course of nonallergic rhinitis is generally rather mild and less likely to be associated with allergic comorbidities than allergic rhinitis. Here, we aimed to estimate the rate of coexisting comorbidities of nonallergic rhinitis. Nonallergic rhinitis is more prevalent during the first 2 years of life; however, its underestimation for children with atopic tendencies is likely due to low positive rates of specific allergic tests during early childhood. Local allergic rhinitis is a recently noted phenotype with rates similar to those in adults (median, 44%; range, 4%-67%), among patients previously diagnosed with nonallergic rhinitis. Idiopathic rhinitis, a subtype of nonallergic rhinitis, has been poorly studied in children, and its rates are known to be lower than those in adults. The prevalence of nonallergic rhinitis with eosinophilia syndrome is even lower. A correlation between nonallergic rhinitis and pollution has been suggested owing to the recent increase in nonallergic rhinitis rates in highly developing regions such as some Asian countries, but many aspects remain unknown. Conventional treatments include antihistamines, intranasal corticosteroids, and recent treatments include combination of intranasal corticosteroids with azelastin or decongestants. Here we review the prevalence, diagnosis, comorbidities, and treatment recommendations for nonallergic rhinitis versus allergic rhinitis in children.

[Diagnosis of allergy in asthma]

Allergy is a hypersensitivity reaction induced by immunological mechanisms. In asthma, allergy has a complex role and is usually IgE mediated. Allergy must be evaluated during the work up but evidence of IgE sensitivity does not mean that allergens play a role in the pathophysiology of the disease. The clinical relevance of the sensitivity has to be considered. This paper describes current available tools to screen for IgE sensitivity, allergen exposure and their role in asthma.

[Relevance of nasal provocation testing in house dust mite allergy]

Patients with house dust mite allergies frequently exhibit very different symptoms to those allergic to other inhalant allergens. The frequency of comorbid allergic asthma in these patients is increased. Therefore, diagnosing patients with suspected house dust mite allergies can be difficult. It is important to distinguish between sensitization to an allergen and a clinically relevant allergy. Nasal provocation testing (NPT) is a reliable method to identify patients suitable for a causal treatment (specific immunotherapy). Position papers on methodology and interpretation of NPT data are available. Skin prick and allergen-specific IgE tests reveal a reasonable correlation with NPT results, although this is inexact to some extent. Performance of NPT in patients with suspected house dust mite allergy is important in individuals with questionable symptoms and unclear skin and blood test results, particularly prior to initiation of allergen immunotherapy.

Validation of Strasbourg environmental exposure chamber (EEC) ALYATEC® in mite allergic subjects with asthma

Objective: Environmental Exposure Chamber (EEC) should have standardized and controlled allergenic and non-allergenic exposures to perform reproducible clinical studies. The aim was to demonstrate that mite exposure in the Alyatec^® EEC could induce early (EAR) and/or late asthmatic reactions (LAR) in at least 60% of subjects allergic to mite.Methods: The EEC has a volume of 147-m³ with 20 seats. The nebulized particle number, airborne Der p1, endotoxins, and volatile organic compound (VOC) concentrations were measured. Twenty-four asthmatics allergic to mite were randomly exposed to 15, 25, and 46 ng/m³ Der p1. Specificity was assessed in not mite-sensitized asthmatics.Results: No significant endotoxin or VOC contamination was measured. The mean inter-assay CVs were 12.5% for the airborne particle number and 28.7% for airborne Der p1 concentrations. For the three Der p1 concentrations, at least 88% of the subjects developed EAR and/or LAR, and at least 46% developed a dual response. No reaction occurred with placebo or in the control group. No severe bronchial reaction occurred.Conclusions: The Alyatec^® EEC demonstrated a tight control of allergenic and non-allergenic exposures. The EEC was clinically validated, with airborne Der p1 levels close to levels found in natural settings.

Standard-dose versus low-dose multidetector computed tomography examinations in patients with uncontrolled chronic rhinosinusitis: A randomized, controlled trial

BACKGROUND

Multidetector computed tomography (MDCT) images for rhinosinusitis may have a risk of radiation hazards. Reduction in radiation dose may lead to a compromise in quality of MDCT images and have chances of postoperative complications.

OBJECTIVE

The aim of the study was to test the applicability of low-dose MDCT protocols for decision-making of sinus surgeries of patients with uncontrolled chronic rhinosinusitis.

DESIGN

Randomized, double-blind (patients and evaluators blind), controlled, trial.

SETTING

People's Hospital of Guanghan, China.

PATIENTS

A total of 288 patients with clinically confirmed uncontrolled chronic rhinosinusitis were subjected to randomization (1:1 ratio).

INTERVENTIONS

Patients were subjected to low-dose preoperative protocols of MDCT (n = 144; ldMDCT group) or standard-dose preoperative protocols of MDCT (n = 144; sdMDCT group).

OUTCOME MEASURES

Image analysis was performed by the workstation. Lund-Mackay score, modified Lund-Mackay score, estimated radiation exposure, and surgical complications were evaluated for each patient. The χ independent test or 2-tailed paired t test were performed for statistical analysis.

RESULTS

The preoperative MDCT images for standard-dose protocol had better quality than low-dose protocol (P < .001, q = 4.57). The area of images that give confidence for sinus surgery at one time was higher for standard-dose MDCT protocol technique than low-dose MDCT protocol method. Patients of ldMDCT group with large growth of nasal polyps (P = .03, q = 5.35) and complete opacification of sinuses (P = .03, q = 7.94) had complications after sinus surgeries. Either low-dose or standard-dose MDCT protocol was performed, the experience of otolaryngologist had decreased complication after surgeries.

CONCLUSION

Preoperative low-dose MDCT should be used for diagnosis of uncontrolled chronic rhinosinusitis for decision making of sinus surgeries.

LEVEL OF EVIDENCE

III.

TRIAL REGISTRATION

researchregistry4264 dated 1 March 2016 (www.researchregistry.com).

[The usefulness of nasal provocation tests for respiratory physicians]

Rhinitis and asthma are common diseases that are strongly linked from both the epidemiological and patho-physiological point of view. A precise aetiological diagnosis is required in order to optimize treatment. Nasal provocation tests (NPT) determine precisely the role of the allergen in the initiation of the symptoms of rhinitis particularly when the history does not produce convincing evidence of the clinical relevance of an allergen. It may also have important consequences for the choice of an allergenic immunotherapy. NPT are not standardized but simple methods based on international recommendations provide us with good diagnostic accuracy. In this paper, we will discuss the practical aspects of NPT as well as the clinical or research situations where they may be useful for the respiratory physician.

Molecular allergy diagnostics refine characterization of children sensitized to dog dander

BACKGROUND

Sensitization to dog dander is an important risk factor for rhinoconjunctivitis and asthma but is not sufficient for diagnosing dog allergy. Molecular allergy diagnostics offer new opportunities for refined characterization.

OBJECTIVES

We sought to study the association between sensitization to all presently known dog allergen components and clinical symptoms of dog allergy in children evaluated by using nasal provocation tests (NPTs).

METHODS

Sixty children (age, 10-18 years) sensitized to dog dander extract underwent NPTs with dog dander extract. Measurement of IgE levels to dog dander and to Can f 1, Can f 2, Can f 3, and Can f 5 was performed with ImmunoCAP, and measurement of IgE levels to Can f 4 and Can f 6 was performed with streptavidin ImmunoCAP. An IgE level of 0.1 kU_A/L or greater was considered positive.

RESULTS

There was an association between sensitization to an increasing number of dog allergen components and a positive nasal challenge result (P = .01). Sensitization to lipocalins (odds ratio [OR], 6.0; 95% CI, 1.04-34.5), in particular Can f 4 (OR, 6.80; 95% CI 1.84-25.2) and Can f 6 (OR, 5.69; 95% CI, 1.59-20.8), was associated with a positive NPT result. Monosensitization to Can f 5 was related to a negative NPT result (OR, 5.78; 95% CI, 1.01-33.0).

CONCLUSION

Sensitization to an increasing number of dog allergen components and to lipocalins is associated with dog allergy. Monosensitization to Can f 5 should not be regarded primarily as a marker for dog allergy.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

How In Vitro Assays Contribute to Allergy Diagnosis

Diagnosis of allergic disorders is based upon the clinical history of the disease, the immunoglobulin E (IgE) antibody response, and the allergen exposure. During the last decade, many changes have occurred in the in vitro diagnostic tests used in daily practice. The most important one is the use of allergenic molecules, which helps to define severe profile of allergy and/or to better understand cross-reactivity. The correlation between IgE sensitization and bronchial or nasal response in provocation tests is not so clear, which implies that such tests are still helpful in allergy diagnosis. In order to strengthen the link between a real allergen exposure and allergic symptoms, environmental allergen load assessment can be performed. For clinicians, it appears obvious to know the pollen count to treat their patients; however, they rarely measure the allergen load in the indoor environment, while nowadays home-tests (semi-quantitative or quantitative) make the assessment very easy. In the future, assessment of the environmental exposure (preferably with an indoor technician) of an allergic patient should take into account not only the allergens but also the other indoor pollutants, which could enhance respiratory symptoms in allergic patients.

Specific Nasal Provocation Test with Dermatophagoides Pteronyssinus, Monitored by Acoustic Rhinometry, in Children with Rhinitis

Background

Currently, the diagnosis of allergic rhinitis (AR) is arrived at predominantly by a clinical history and by systemic sensitization tests, but specific nasal provocation tests (NPT) may establish a better direct correlation between etiologic surveyed allergens and nasal symptoms.

Objectives

To standardize the specific NPT with one of the most important house-dust mites, Dermatophagoides pteronyssinus, monitored by acoustic rhinometry, in children and adolescents, and propose a simplified specific NPT to improve its clinical applicability as a diagnostic tool.

Methods

Sixteen controls (group 1) and 17 patients with an AR diagnosis sensitized to D. pteronyssinus (group 2) underwent a specific NPT with D. pteronyssinus. The acoustic rhinometry was performed after instillation of 0.15 mL of increasing concentrations of D. pteronyssinus (5000 BU/mL). The test was finalized after (1) instillation of the final concentration of D. pteronyssinus, or (2) after a 20% or more reduction in the volume of the first 5 cm of the nasal cavity (V5), or (3) a score of >3 in the symptoms questionnaire (a score from 0 to 7). A simplified specific NPT with two concentrations was proposed and implemented in a group of 10 patients with AR (group 3).

Results

At the end of the specific NPT, the median (range) variation in V5 was -5.7% (-9 to 4%) in the control group and -22.8% (-24 to -20%) in group 2. None of the patients in the control group and 88% of group 2 (15/17) showed positive specific NPT results. The simplified specific NPT triggered a positive response in 80% of patients in group 3, with median (range) V5 variation of -30.4% (-36 to -20%).

Conclusion

This protocol has been proven safe and useful to differentiate between children and adolescents with AR and controls. Concentrations of 1:1000 and 1:100 D. pteronyssinus were the best for use in simplified specific NPT, which made it simpler and faster, and expanded its clinical applicability.

Specificity and sensitivity assessment of selected nasal provocation testing techniques

Introduction

Nasal provocation testing involves an allergen-specific local reaction of the nasal mucosa to the administered allergen.

Aim

To determine the most objective nasal occlusion assessment technique that could be used in nasal provocation testing.

Material and methods

A total of 60 subjects, including 30 patients diagnosed with allergy to common environmental allergens and 30 healthy subjects were enrolled into the study. The method used in the study was a nasal provocation test with an allergen, with a standard dose of a control solution and an allergen (5,000 SBU/ml) administered using a calibrated atomizer into both nostrils at room temperature. Early-phase nasal mucosa response in the early phase of the allergic reaction was assessed via acoustic rhinometry, optical rhinometry, nitric oxide in nasal air, and tryptase levels in the nasal lavage fluid.

Results

In estimating the homogeneity of the average values, the Levene’s test was used and receiver operating characteristic curves were plotted for all the methods used for assessing the nasal provocation test with an allergen. Statistically significant results were defined for p < 0.05. Of all the objective assessment techniques, the most sensitive and characteristic ones were the optical rhinometry techniques (specificity = 1, sensitivity = 1, AUC = 1, PPV = 1, NPV = 1).

Conclusions

The techniques used showed significant differences between the group of patients with allergic rhinitis and the control group. Of all the objective assessment techniques, those most sensitive and characteristic were the optical rhinometry.