Molecular pathology of allergic disease. II: Upper airway disease

Therapeutic potential of the topical recombinant human interleukin-1 receptor antagonist in guinea pigs with allergic rhinitis

BACKGROUND

Recombinant human Interleukin receptor antagonist (rhIL-Ra) can bind to the IL-1 receptor on the cell membrane and reversibly blocks the proinflammatory signaling pathway. However, its effect on allergic rhinitis (AR) and the underlying mechanism remains unknown. This study aims to investigate the efficacy of recombinant human interleukin-1 receptor antagonist (rhIL-1Ra) on AR guinea pigs.

METHODS

Guinea pigs were systemically sensitized by intraperitoneal injection and topical intranasal instillation with ovalbumin within 21 days. Animals administrated with saline served as the normal control. The AR animals were randomly divided into the model group and distinct concentrations of rhIL-1Ra and budesonide treatment groups. IL-1β and ovalbumin specific IgE levels were detected by ELISA kits. Nasal mucosa tissues were stained with hematoxylin & eosin (HE) for histological examination.

RESULTS

It was found that the numbers of sneezing and nose rubbing were remarkably reduced in rhIL-1Ra and budesonide-treated guinea pigs. Besides, rhIL-1Ra distinctly alleviated IgE levels in serum and IL-1β levels in nasal mucus, together with decreased exfoliation of epithelial cells, eosinophilic infiltration, tissue edema and vascular dilatation.

CONCLUSIONS

rhIL-1Ra is effective in AR guinea pigs and may provide a novel potential choice for AR treatments.

Comorbid asthma is associated with rhinitis severity in children exposed to air pollutants

BACKGROUND

The impact of asthma on the severity of rhinitis when children with allergic rhinitis (AR) are exposed to air pollutants has not been studied.

METHODS

Children with AR (65 with asthma, 208 without asthma), aged 6-13 years, were recruited from a hospital in Taichung, Taiwan, between 2007 and 2011. Correlations between Pediatric-Rhinoconjunctivitis-Quality-of-Life score, nasal peak expiratory flow, and air pollutants were compared. With the same age, research time, and form the same city, children with AR (660 with asthma, 3174 without asthma) were selected from a database. Correlations between clinical visit times for AR and air pollutants were compared.

RESULTS

In male children with AR and asthma, both clinical and database studies revealed a correlation between higher rhinitis discomfort (quality-of-life score), higher visit times for AR, and higher PM10, PM2.5, NO2, NMHC concentrations. Correlations between higher nasal inflammation/obstruction (lower expiratory flow) and higher air pollutant concentrations were observed in male children with AR and asthma.

CONCLUSION

In children with AR, comorbid asthma was associated with increased rhinitis severity when they were exposed to air pollutants, and the association was only noted in males. Increased nasal obstruction/inflammation from exposure to air pollutants may be the mechanisms underlying this association.

IMPACT STATEMENT

The influence of asthma on the severity of rhinitis when children with allergic rhinitis (AR) are exposed to air pollutants has not been studied. In children with AR, the correlation between higher rhinitis discomfort, higher number of clinical visits for AR, and higher PM10, PM2.5, NO2, NMHC concentrations were only noted in those who also had asthma. The correlation was only noted in male. Comorbid asthma was associated with higher rhinitis severity when children with AR are exposed to air pollutants The association was only noted in male.

The Impact of Cytokines on Health-Related Quality of Life in Adolescents with Allergic Rhinitis

BACKGROUND

Frequent episodes of nasal symptoms are the usual clinical manifestations (CM) of allergic rhinitis (AR) and have a significant negative impact on health-related quality of life (HRQoL) in adolescents. The purpose of this cross-sectional study was to test the hypothesis that cytokines in nasal mucus may be associated with HRQoL in adolescents with AR.

METHODS

European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L), "The Adolescent Rhinoconjunctivitis Quality of Life Questionnaire" (AdolRQLQ) and the Total 4 Symptom Score (T4SS) scoring system were administered to 113 adolescents with AR, nonallergic rhinitis (NAR) and to healthy control subjects. Nasal secretions were sampled and tested for 13 cytokines using a multiplex flow cytometric bead assay.

RESULTS

The AR group had significantly lower EQ-5D-3L (0.661 ± 0.267 vs. 0.943 ± 0.088; p < 0.001) and higher AdolRQLQ total scores (2.76 ± 1.01 vs. 1.02 ± 0.10; p < 0.001) compared to the control group. The AR group had higher concentrations of IL-1β (p = 0.002), IL-6 (p = 0.031), IL-8 (p < 0.001), IL17-A (p = 0.013) and IL-18 (p = 0.014) compared to the control group, and IL-1β, IL-6, IL17-A and IL-18 were significantly (p < 0.050) increased with disease progression. Cytokines IL-1β, IL-6, as well as severe CM, were identified as significant predictors of lower HRQoL in adolescents with AR.

CONCLUSIONS

This study identified IL-1β, IL-6, as well as severe CM, as predictors of lower HRQoL in adolescents with AR. However, these results should only serve as a starting point for additional confirmation research.

Role of Probiotics in Patients with Allergic Rhinitis: A Systematic Review of Systematic Reviews

Introduction  Allergic rhinitis (AR) is estimated to affect up to 30% of the world population. With the rise in cases, newer treatment modalities have been explored. Probiotics have shown to reduce symptoms of AR and improve quality of life. A few systematic reviews have been published aiming to assess the role of probiotics in AR. Objectives  To consolidate the recent evidence with an overview of systematic reviews by extracting data regarding subjective outcomes (from quality of life questionnaires, the Total Nasal Symptom Score, the Total Ocular Symptom Score, the Daily Total Symptom Score, the incidence of AR, and the Rhinitis Total Symptom Score) and objective outcomes (levels of antigen-specific immunoglobulin E [IgE], total IgE, interleukin 10 [IL-10], interferon gamma [IFNG], eosinophil, and the T helper 1/T helper 2 [Th1/Th2] ratio). Data Synthesis  We conducted a literature search on the PubMed, EBSCO CINAHL, EBSCO Dentistry & Oral Sciences Source, and Cochrane Library up to April 14, 2020. The qualitative assessment was performed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR-2) tool. A total of 419 titles were screened, and 3 systematic reviews met our eligibility criteria. Probiotics in the treatment of AR have been shown to improve quality of life, the total nasal and ocular symptom scores, the daily total symptom scores and Th1/Th2 ratio. No difference was ascertained for rhinitis total symptom score, and the rates of antigen-specific IgE, total IgE, IL-10, INFG and eosinophil. Conclusion  The present review showed that there is considerable evidence that probiotics are useful in the treatment of AR. Further randomized trials targeting the limitations of the currently-available evidence can help ascertain the usefulness of probiotics in cases of AR.

The Assessment of TNF-α Gene Polymorphism Association with the Risk of Allergic Rhinitis in the Chinese Han Population

BACKGROUND

Allergic rhinitis (AR) is a non-infectious chronic inflammatory disease of the nasal mucosa that is mainly mediated by IgE after exposure to allergens. Tumor necrosis factor-α has been found to be involved in inflammation response. In the present study, we screened several SNPs of TNF-α gene and analyzed the associations between target SNPs polymorphism and AR.

METHODS

Using an unmatched case-control design, 600 AR patients and 600 healthy controls were enrolled. General characteristics were collected including IgE expression. Univariate and multivariate logistic regression were used to estimate the odds ratio (OR) and 95% confidence interval (CI) of TNF-α gene for AR in dominant model, additive model, recessive model and allele model. The haplotype analyses were performed using rs1799964, rs1800630 and rs769178. Stratified analyses were also performed in gender, age, overweight, smoking, drinking, family history, and asthma history.

RESULTS

Our multivariate logistic regression indicated that rs1799964, rs1800630 and rs769178 locus polymorphisms are not associated with AR. For rs769178, the GT (OR=2.35, 95% CI:1.82-3.03, P<0.001) and GT+TT (OR=1.89, 95% CI: 1.50-2.38, P<0.001) genotypes present an increased risk for AR compared to GG. The C-G-A-T (OR=2.04, 95% CI: 1.21-3.44, P=0.007) and C-G-C-T (OR=1.29, 95% CI: 1.04-1.62, P=0.024) haplotypes are associated with the increased risk of AR, and the C-G-C-G haplotypes decreased risk of AR (OR=0.75, 95% CI: 0.63-0.88, P=0.001). Stratified analyses shown a significant association between recessive model of rs769178 locus and AR risk in the subgroup of age≤60, overweight and smoking. Cross-over analysis indicated that the effects of TT+GT of genotype combined with smoking or drinking related with AR were associated with AR risk.

CONCLUSION

The rs769178 locus polymorph of TNF-α was associated with an increased risk of AR. The haplotypes (C-G-A-T and C-G-C-T) of TNF-α can significantly increase the risk of AR, and C-G-C-G haplotype decreased the risk of AR. There are interactions between rs769178 polymorphism and smoking/drinking for AR risk.

Outdoor pollen-related changes in lung function and markers of airway inflammation: A systematic review and meta-analysis

BACKGROUND

Experimental challenge studies have shown that pollen can have early and delayed effects on the lungs and airways. Here, we qualitatively and quantitatively synthesize the evidence of outdoor pollen exposure on various lung function and airway inflammation markers in community-based studies.

METHODS

Four online databases were searched: Medline, Web of Science, CINAHL and Google Scholar. The search strategy included terms relating to both exposure and outcomes. Inclusion criteria were human-based studies published in English that were representative of the community. Additionally, we only considered cross-sectional or short-term longitudinal studies which investigated pollen exposure by levels or season. Study quality assessment was performed using the Newcastle-Ottawa scale. Meta-analysis was conducted using random-effects models.

RESULTS

We included 27 of 6551 studies identified from the search. Qualitative synthesis indicated associations between pollen exposure and predominantly type-2 inflammation in both the upper and lower airways, but little evidence for lung function changes. People with ever asthma and/or seasonal allergic rhinitis (SAR) were at higher risk of such airway inflammation. Meta-analysis confirmed a positive relationship between pollen season, eosinophilia and eosinophil cationic protein (ECP) in people with ever SAR but the results between studies were highly variable. Heterogeneity was reduced after further subgrouping by age, and the forest plots indicated that eosinophilic airway inflammation to outdoor pollen exposure increased with age.

CONCLUSION

Among people with ever asthma and ever SAR, exposure to increased ambient pollen triggers type-2 upper and lower airway inflammation rather than a non-specific or innate inflammation. These findings can lead to the formulation of specific pollen immunotherapy for susceptible individuals. Future research should be directed towards investigating lagged associations and effect modifications using larger and more generalized populations.

SYSTEMATIC REVIEW REGISTRATION

CRD42020146981 (PROSPERO).

Bacillus clausii, a Foreshore-Derived Probiotic, Attenuates Allergic Airway Inflammation Through Downregulation of Hypoxia Signaling

Background and Objectives: The immunomodulatory effects and mechanism of probiotics in allergic airway disease are largely unknown. We studied whether <i>Bacillus clausii</i> (BC), a probiotic derived from mudflats, had anti-allergic effects and compared the results with those of <i>Lactobacillus paracasei</i> (LP). We also examined whether the anti-allergic mechanisms of probiotics are associated with hypoxia signaling.Materials and Method: Forty-two BALB/c mice were randomly assigned to six experimental groups: controls, ovalbumin (OVA)-induced mice for inducing asthma, and OVA-induced mice that were orally administered LP or BC, at 1×10⁹ or 5×10⁹ CFU/mL each. We performed differential cell count testing on bronchoalveolar lavage fluid (BALF), lung histopathology, serum totals and OVA-specific IgE and IgG1 assessments, Th2 cytokine titers (IL-4, IL-5) in BALF and pulmonary parenchyma, quantitative PCR for <i>heme oxygenase (HO)-1</i> and <i>Hif-1α</i>, and immunohistochemistry.Results: Compared to the OVA group mice, OVA-sensitized mice treated with LP or BC showed significantly reduced numbers of eosinophils and neutrophils in the BALF (p<0.05). Both probiotics also significantly reduced pulmonary inflammation and eosinophil infiltration. Mice in the LP or BC group had a substantially lower titer of IL-4 and IL-5 in BALF, and decreased IL-4 and IL-5 expression in the lung parenchyma. Real-time PCR and immunohistochemistry showed that both LP and BC could significantly suppress <i>HO-1</i> and <i>Hif-1α</i> expression in asthmatic mice (p<0.05).Conclusion: BC can attenuate murine allergic asthma by regulating HIF-1α signaling, and its anti-allergic effect is comparable to that of LP.

Could FeNO Predict Asthma in Patients with House Dust Mites Allergic Rhinitis?

Background and Objectives: The evolution of allergic rhinitis to asthma is a part of "atopic march". The aim of this study was to analyze possible predictive markers for asthma occurrence in patients with allergic rhinitis to house dust mites (HDM). Materials and Methods: Fifty-eight patients with persistent allergic rhinitis (PAR) were included. The clinical, biological evaluation and fractionated exhaled nitric oxide (FeNO) measurement were performed at enrolment. The patients were clinically evaluated after one year to determine asthma occurrence. Results: The severity of rhinitis symptoms, levels of total immunoglobulin E (IgE), ICAM-1, VCAM-1, E-selectin and IL-6, but not IL-8 and TNF-α were higher in patients with allergic rhinitis who developed asthma compared to non-asthmatics, but the differences were not significant to considered them as predictive factors for asthma occurrence. The risk of asthma was independently influenced by patients aged over 30 years ((OR-3.74; CI95% 0.86-16.31; p = 0.07), a duration of allergic rhinitis over 12 months ((OR-4.20; CI95% 0.88-20; p = 0.07) and a basal FeNO over 28 parts per billion (pbb) ((OR-18.68; CI95% 3.79-92.05; p < 0.001). Conclusion: Clinical and biological parameters may predict asthma occurrence in patients with persistent allergic rhinitis to HDM. Adult patients with a longer duration of rhinitis symptoms and a high level of FeNO have a greater risk to develop asthma.

IL-2 modulates Th2 cell responses to glucocorticosteroid: A cause of persistent type 2 inflammation?

Background

Glucocorticosteroids (GCs) are the main treatment for asthma as they reduce type 2 cytokine expression and induce apoptosis. Asthma severity is associated with type 2 inflammation, circulating Th2 cells and higher GC requirements.

Objective

The aim of this study was to assess whether ex vivo production of interleukin 2 (IL‐2), a T‐cell survival factor, associated with clinical features of asthma severity, the proportion of blood Th2 cells and Th2 cell responses to GC.

Methods

Peripheral blood from asthma patients (n = 18) was obtained and the proportion of Th2 cells determined by flow cytometry. Peripheral blood cells were activated with mitogen (24 hours) and supernatant levels of IL‐2 and IL‐13 measured by enzyme‐linked immunosorbent assay. In vitro differentiated Th2 cells were treated with dexamethasone (DEX) and IL‐2 and assessed for apoptosis by flow cytometry (annexin V). Level of messenger RNA (mRNA) for antiapoptotic (BCL‐2) and proapoptotic (BIM) genes, IL‐13, GC receptor (GR) and FKBP5 were determined by quantitative real‐time polymerase chain reaction. GR binding was assessed by chromatin immunoprecipitation.

Results

IL‐2 produced by activated peripheral blood cells correlated negatively with lung function and positively with a daily dose of inhaled GC. When patients were stratified based on IL‐2 level, high IL‐2 producers made more IL‐13 and had a higher proportion of circulating Th2 cells. In vitro, increasing the level of IL‐2 in the culture media was associated with resistance to DEX‐induced apoptosis, with more BCL‐2/less BIM mRNA. Th2 cells cultured in high IL‐2 had more IL‐13, less GR mRNA, showed reduced binding of the GR to FKBP5, a known GC‐induced gene, and required higher concentrations of DEX for cytokine suppression.

Conclusions and Clinical Relevance

IL‐2 downregulates Th2 cell responses to GC, supporting both their survival and pro‐inflammatory capacity. These results suggest that a patient's potential to produce IL‐2 may be a determinant in asthma severity.

Chinese Society of Allergy Guidelines for Diagnosis and Treatment of Allergic Rhinitis

Allergic rhinitis (AR) is a global health problem that causes major illnesses and disabilities worldwide. Epidemiologic studies have demonstrated that the prevalence of AR has increased progressively over the last few decades in more developed countries and currently affects up to 40% of the population worldwide. Likewise, a rising trend of AR has also been observed over the last 2-3 decades in developing countries including China, with the prevalence of AR varying widely in these countries. A survey of self-reported AR over a 6-year period in the general Chinese adult population reported that the standardized prevalence of adult AR increased from 11.1% in 2005 to 17.6% in 2011. An increasing number of Journal Articles and imporclinical trials on the epidemiology, pathophysiologic mechanisms, diagnosis, management and comorbidities of AR in Chinese subjects have been published in international peer-reviewed journals over the past 2 decades, and substantially added to our understanding of this disease as a global problem. Although guidelines for the diagnosis and treatment of AR in Chinese subjects have also been published, they have not been translated into English and therefore not generally accessible for reference to non-Chinese speaking international medical communities. Moreover, methods for the diagnosis and treatment of AR in China have not been standardized entirely and some patients are still treated according to regional preferences. Thus, the present guidelines have been developed by the Chinese Society of Allergy to be accessible to both national and international medical communities involved in the management of AR patients. These guidelines have been prepared in line with existing international guidelines to provide evidence-based recommendations for the diagnosis and management of AR in China.

Role of FEF25–75 as an Early Marker of Bronchial Impairment in Patients with Seasonal Allergic Rhinitis

Background

Allergic rhinitis may be associated with asthma. Forced expiratory flow between 25 and 75% of vital capacity (FEF25–75) is a measure of small airways narrowing. The aim of this study was to evaluate whether patients with seasonal allergic rhinitis (SAR) without symptoms of asthma might, nevertheless, have airways obstruction both in and out of the pollen season.

Methods

Fifty patients (mean age, 23.7 ± 4.9 years) with SAR were evaluated both during and outside the pollen season. All of them had moderate–severe grade of nasal obstruction. Total symptom score, rhinomanometry, nasal lavage, nasal scraping, spirometry, and methacholine (MCH) bronchial challenge were assessed in all subjects.

Results

Although data on forced vital capacity and response to MCH were similar in and out of the pollen season, all other parameters were markedly different. The major finding of the study was that FEF25–75 was significantly associated with nearly all of the parameters considered, including bronchial hyperreactivity, with Pearson R ranging from 31 to 75% and differences in mean FEF25–75 ranging between 14.5 and 16.5% of predicted. The more significant association was with nasal airflow in the pollen season (R = 82.8%; p < 0.001). A significant association persisted for all parameters while controlling for season.

Conclusion

This study highlights the link between upper and lower airways and the role of FEF25–75 as an early marker of bronchial impairment in those patients with SAR alone.

Nitric Oxide and Collagen Expression in Allergic Upper-Airway Disease

Background

The presence of nitric oxide (NO) in high concentrations has been described in the nasal mucosa of patients with untreated allergic rhinitis. We sought to examine the role of exogenous, as well as endogenous, NO in the production of collagen type I and type III by human nasal fibroblasts.

Methods

Primary cultured fibroblasts derived from eosinophilic nasal polyps were exposed to NO donors (500 μM of S-nitroso-N-acetyl-d,l-penicillamine (SNAP) 1000 μM of 3,3-bis(aminoethyl)-1-hydroxy-2-oxo-1-triazene (DETA-NONOate)) and various other compounds over a 24-hour incubation period. Collagen production was evaluated qualitatively by immunocytochemistry and quantitatively by Western blot analysis.

Results

Maximally stimulated fibroblasts established a 2.2-fold increase in the production of type III collagen relative type I, as compared with baseline. Oxyhemoglobin, an NO scavenger, abolished this effect. SNAP (500 μM) caused a 15.68 ± 0.68% increase in collagen type I synthesis as compared with unstimulated controls (p < 0.05). In contrast, incubation with SNAP caused an increase in collagen type III production by a factor of 34.68 ± 0.32% (p < 0.05).

Conclusion

NO stimulates collagen expression in human nasal polyp-derived fibroblasts. This stimulation appeared to favor the up-regulation of collagen type III, leading to a shift in the ratio of collagen type I to type III production.

Cow's Milk and Immune Function in the Respiratory Tract: Potential Mechanisms

During the last decades, the world has witnessed a dramatic increase in allergy prevalence. Epidemiological evidence shows that growing up on a farm is a protective factor, which is partly explained by the consumption of raw cow’s milk. Indeed, recent studies show inverse associations between raw cow’s milk consumption in early life and asthma, hay fever, and rhinitis. A similar association of raw cow’s milk consumption with respiratory tract infections is recently found. In line with these findings, controlled studies in infants with milk components such as lactoferrin, milk fat globule membrane, and colostrum IgG have shown to reduce respiratory infections. However, for ethical reasons, it is not possible to conduct controlled studies with raw cow’s milk in infants, so formal proof is lacking to date. Because viral respiratory tract infections and aeroallergen exposure in children may be causally linked to the development of asthma, it is of interest to investigate whether cow’s milk components can modulate human immune function in the respiratory tract and via which mechanisms. Inhaled allergens and viruses trigger local immune responses in the upper airways in both nasal and oral lymphoid tissue. The components present in raw cow’s milk are able to promote a local microenvironment in which mucosal immune responses are modified and the epithelial barrier is enforced. In addition, such responses may also be triggered in the gut after exposure to allergens and viruses in the nasal cavity that become available in the GI tract after swallowing. However, these immune cells that come into contact with cow’s milk components in the gut must recirculate into the blood and home to the (upper and lower) respiratory tract to regulate immune responses locally. Expression of the tissue homing-associated markers α4β7 and CCR9 or CCR10 on lymphocytes can be influenced by vitamin A and vitamin D3, respectively. Since both vitamins are present in milk, we speculate that raw milk may influence homing of lymphocytes to the upper respiratory tract. This review focuses on potential mechanisms via which cow’s milk or its components can influence immune function in the intestine and the upper respiratory tract. Unraveling these complex mechanisms may contribute to the development of novel dietary approaches in allergy and asthma prevention.

Changes in IL-4 and IL-13 expression in allergic-rhinitis treated with hydrogen-rich saline in guinea-pig model

BACKGROUND

Medical gas hydrogen (H₂) has a special role in airway inflammation; however, the effect of H₂ on allergic rhinitis (AR) remains unclear. This study explored the possible roles of H2 on the pathogenesis of AR and observed the influences of H₂ on cytokines IL-4 and IL-13.

METHODS

An AR guinea pig model was established by nasal ovalbumin sensitisation. Eighteen guinea pigs were divided into three groups, namely, saline control, AR-sensitised, and hydrogen-rich saline (HRS)-treated groups, with each group having six guinea pigs. The frequencies of sneezing and scratching were recorded. The IgE level and cytokine (IL-4 and IL-13) levels in the serum were measured. The expression levels of IL-4 and IL-13 mRNA and protein in the nasal mucosa were also determined by real-time reverse transcriptase-polymerase chain reaction and Western blot. We also observed the infiltration of cytokine (IL-4 and IL-13) in nasal mucosa by immunofluorescence.

RESULTS

The frequencies of sneezing and scratching, as well as the levels of IgE, IL-4, and IL-13, in the serum were higher in the AR group than in the control group (p<0.01), whereas all these parameters were decreased significantly after HRS treatment (p<0.05). The expression levels of IL-4 and IL-13 mRNA and protein in the nasal mucosa were also lower in guinea pigs treated with HRS than those in the AR group (p<0.05).

CONCLUSIONS

HRS could affect anti-inflammation in AR and decreased the expression of IL-4 and IL-13.

Nasal Obstruction is the Key Symptom in Hay Fever Patients

BACKGROUND: Allergic rhinitis is characterized by a Th2-dependent inflammation. Nasal obstruction largely depends on allergic inflammation.

OBJECTIVE: The aim of this study was to evaluate the possible role of the symptom nasal obstruction in assessing patients with hay fever.

METHODS: Fifty patients (mean age, 23.7 ± 4.9 years) with hay fever were evaluated both during and outside pollen season. All of them had moderate-severe grade of nasal obstruction. Total symptom score (TSS), rhinomanometry, nasal lavage, nasal scraping, spirometry, and methacholine bronchial challenge were performed in all subjects.

RESULTS: During the pollen season, patients with severe nasal obstruction showed significantly higher values of TSS, IL-4, IL-5, IL-8, nasal eosinophils and neutrophils, and significantly lower values of nasal airflow, IFNγ, FEV1, FVC, and FEF 25-75 in comparison with patients with moderate nasal obstruction. Twenty (83%) patients with severe nasal obstruction showed bronchial hyperreactivity (BHR), whereas only 6 (25%) patients with moderate nasal obstruction had BHR. Outside the pollen season overlapping results were observed.

CONCLUSIONS: This study provides evidence about the key role played by nasal obstruction in assessing patients with allergic rhinitis.

The role of probiotics in prevention and treatment for patients with allergic rhinitis: A systematic review

BACKGROUND

Allergic rhinitis (AR) is a disease of respiratory allergy, and probiotics can provide a potential strategy for its management. The purpose of this study was to carry out a systematic review to investigate the role of probiotics in the prevention and treatment of AR.

METHODS

We searched for randomized controlled trials (RCTs) of the use of probiotics for the prevention and treatment of AR in the major electronic databases up to March 2014. The quality of the included RCTs was evaluated, and the data were independently extracted by two assessors. Meta-analyses were performed. Continuous data were expressed as the mean difference (MD) or standardized MD with 95% confidence interval (CI). Dichotomous data were expressed as odds ratio with the 95% CI. A p value <0.05 was considered significant.

RESULTS

A total of 11 RCTs were included in the analysis. Probiotic intake was associated with a significant overall improvement of the quality of life scores and nasal symptom scores of patients with AR (MD -2.97 [95% CI, -4.77 to -1.16)]; p = 0.001). No improvements with regard to prevention or immunologic parameters were noted in the patients with AR.

CONCLUSIONS

The current evidence is not sufficiently strong to verify a preventive role of probiotics in AR, but probiotics may improve the overall quality of life and nasal symptom scores. Because the available data were generated from only a few trials with a high degree of heterogeneity, routine use of probiotics for prevention and treatment in patients with AR cannot be recommended.

The messenger between worlds: the regulation of innate and adaptive type-2 immunity by innate lymphoid cells

Although type-2 immune responses evolved primarily to defend against extracellular helminths, in part through the co-opting of tissue repair and remodeling mechanisms, they are often inappropriately directed towards relatively innocuous allergens resulting in conditions including asthma, allergic rhinitis, food allergy, and atopic dermatitis. The recent discovery of group 2 innate lymphoid cells (ILC2) has increased our understanding of the initiation of these responses and the roles played by CD4(+) T helper (Th) 2 cells in their modulation. This review focuses on the important messenger role of ILC2 in translating epithelial-derived alarmins into downstream adaptive type-2 responses via dendritic cells and T cells, with special emphasis on their roles in allergic disease.

Histopathological effects of intranasal phototherapy and nasal corticosteroids in allergic rhinitis in a rabbit model

Allergic rhinitis is one of the most common health problems and has a major effect on quality of life. Although new-generation antihistamines and nasal steroids are the main treatment options, complete resolution cannot be obtained in some patients. Besides common side effects such as nasal irritation and epistaxis, the use of these drugs is controversial in some patients, such as pregnant or breastfeeding women. These findings highlight the need for new treatment options. Although phototherapy has been successfully used in the treatment of atopic dermatitis, which is an IgE-mediated disease and shares several common pathogenic features with allergic rhinitis, there are limited studies about its role in the treatment of allergic rhinitis. In this study, we aimed to evaluate and compare the histopathological effects of intranasal phototherapy (Rhinolight) and nasal corticosteroid treatment on the nasal mucosa in allergic rhinitis in a rabbit model and we found that both treatment options significantly reduced inflammation in the nasal mucosa without increasing apoptosis of mucosal cells.

T cells in chronic rhinosinusitis with nasal polyposis

PURPOSE OF REVIEW

The cause of nasal polyp disease remains controversial. Examination of the T lymphocytes involved in nasal polyp inflammation may lead to an improved understanding of the cause, prognosis, and treatment of chronic rhinosinusitis with nasal polyposis.

RECENT FINDINGS

T lymphocytes are important directors of the inflammatory process in allergic rhinitis and asthma, but the role of T lymphocytes in chronic rhinosinusitis with nasal polyposis has not been thoroughly investigated. The T lymphocyte infiltrate in nasal polyps may vary based upon genetic factors, polyp histology, or the presence of asthma/atopy. Staphylococcal enterotoxins, which are known to activate T cells, stimulate proinflammatory cytokine secretion by nasal polyp cells, whereas regulatory cytokines are not similarly up regulated by enterotoxin exposure. The inflammation in nasal polyps may be related to deficient function of regulatory T cells. New data on staphylococcal enterotoxins and regulatory T cells point to possible roles for T cells in chronic rhinosinusitis with nasal polyposis.

SUMMARY

Further study of the T cell compartment in nasal polyps may lead to a better understanding of the intrinsic and extrinsic factors responsible for nasal polyp inflammation.

Clinical practice guideline: Allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

PURPOSE

The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

ACTION STATEMENTS

The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Regulation of nasal airway homeostasis and inflammation in mice by SHP-1 and Th2/Th1 signaling pathways

Allergic rhinitis is a chronic inflammatory disease orchestrated by Th2 lymphocytes. Src homology 2 domain-containing protein tyrosine phosphatase (SHP)-1 is known to be a negative regulator in the IL-4α/STAT-6 signaling pathway of the lung. However, the role of SHP-1 enzyme and its functional relationship with Th2 and Th1 cytokines are not known in the nasal airway. In this study, we aimed to study the nasal inflammation as a result of SHP-1 deficiency in viable motheaten (mev) mice and to investigate the molecular mechanisms involved. Cytology, histology, and expression of cytokines and chemokines were analyzed to define the nature of the nasal inflammation. Targeted gene depletion of Th1 (IFN-γ) and Th2 (IL-4 and IL-13) cytokines was used to identify the critical pathways involved. Matrix metalloproteinases (MMPs) were studied to demonstrate the clearance mechanism of recruited inflammatory cells into the nasal airway. We showed here that mev mice had a spontaneous allergic rhinitis-like inflammation with eosinophilia, mucus metaplasia, up-regulation of Th2 cytokines (IL-4 and IL-13), chemokines (eotaxin), and MMPs. All of these inflammatory mediators were clearly counter-regulated by Th2 and Th1 cytokines. Deletion of IFN-γ gene induced a strong Th2-skewed inflammation with transepithelial migration of the inflammatory cells. These findings suggest that SHP-1 enzyme and Th2/Th1 paradigm may play a critical role in the maintenance of nasal immune homeostasis and in the regulation of allergic rhinitis.

Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation

The relationship between allergic rhinitis and chronic rhinosinusitis has been assessed in a number of observational and experimental studies. In this review, we attempt their synthesis and evaluation using the modified Bradford Hill guidelines for causation. Although there is no proof of causation, especially in the pediatric literature, an evaluation of underlying allergies is recommended at least as an initial measure of symptoms relief.

New kids on the block: group 2 innate lymphoid cells and type 2 inflammation in the lung

Inflammatory diseases of the lung are a major cause of morbidity and mortality. Allergic lung inflammation often stems from the overproduction of type 2 cytokines. The resulting type 2 inflammation is frequently caused by an inappropriate immune response to relatively harmless allergens and often associates with asthma. Until recently, the primary contributors of type 2 cytokines were believed to be T helper (Th) 2 cells. This concept was challenged by the discovery of group 2 innate lymphoid cells (ILC2s) in the lung, which represent a major source of type 2 cytokines during the acute inflammatory phase. Recent advances in our understanding of the regulation and development of ILC2 have redrawn the roadmap of type 2 inflammation. Indeed, ILC2s appear to be critical for the induction of adaptive immunity and, thus, play a central role for immune regulation. As one of the first responders in the entire Th2 cascade, ILC2 might serve as the early tile in a Th2 domino effect. As such, ILC2s present an attractive target for future drug development.

Correlation between nasal eosinophils and nasal airflows in children with asthma and/or rhinitis monosensitised to house dust mites

BACKGROUND

Allergic rhinitis and asthma due to mite sensitisation are diseases which are frequently associated and characterised by persistent inflammation. In the present study, we aimed to investigate the relationship between nasal airflows and nasal eosinophils in patients with asthma and/or rhinitis due to house dust mite sensitisation.

METHODS

Twenty-four children with both rhinitis and asthma (R+A), 13 children with rhinitis and no asthma (R) and 10 non-allergic healthy children were evaluated prospectively. The patients belonging to the first two groups had moderate-severe grade of nasal obstruction. Total nasal symptom scores, peak nasal inspiratory flows (PNIFs) obtained by anterior rhinomanometry, skin prick tests, nasal eosinophils and FEV1 values were all assessed.

RESULTS

Percentages of nasal eosinophils and PNIFs in patients with R+A and R (r=-0.415, p=0.04) were found to be statistically significant and to have an inverse correlation. Skin prick tests were also significantly correlated with nasal eosinophils and PNIFs (r=0.372, p=0.01 and r=-0.306, p=0.04, respectively). Both PNIFs and nasal eosinophils of patients with R+A were significantly correlated with FEV1 values (r=-0.641, p=0.001 and r=0.548, p=0.007, respectively).

CONCLUSION

In this study, a close relationship was demonstrated between eosinophil infiltration and nasal airflows in children having asthma and/or rhinitis monosensitised to mites. Additionally, the significant association found between FEV1 values and nasal eosinophils or PNIFs supported the close link of upper and lower airways.

Effect of moisture-damage intervention on the immunotoxic potential and microbial content of airborne particles and on occupants' upper airway inflammatory responses

This intervention study evaluated the effect of moisture-damage repairs on the exposure and on the upper airway inflammatory responses of the occupants. The airborne microbial exposure was followed by quantitative PCR analyses of 13 microbial species in repeated long-term indoor air samples before (N = 26) and after (N = 28) repairs of the school building. Airborne particulate matter was collected similarly from the same premises (before N = 25, after N = 34) for determination of nitric oxide (NO), tumor necrosis factor α (TNFα), and interleukin-6 (IL-6), measured in the cell culture medium of mouse macrophages. NO, TNFα, IL-6, and IL-4 were also analyzed in the nasal lavage (NAL) samples of the occupants (N = 13) to characterize their upper airway inflammatory responses during the exposure and after its cessation. After the repairs, concentrations of the measured airborne microbes decreased, the difference being significant for six of 13 species. After renovation, airborne particulate matter also caused significantly lower production of IL-6 and TNF-α in mouse macrophages than the material collected before the renovation. The concentration of IL-4 in the NAL samples was significantly lower after the renovation. These results show that the inflammatory potential of the airborne material decreases after intensive repair of the moisture damage.

Eosinophils in fungus-associated allergic pulmonary disease

Asthma is frequently caused and/or exacerbated by sensitization to fungal allergens, which are ubiquitous in many indoor and outdoor environments. Severe asthma with fungal sensitization is characterized by airway hyperresponsiveness and bronchial constriction in response to an inhaled allergen that is worsened by environmental exposure to airborne fungi and which leads to a disease course that is often very difficult to treat with standard asthma therapies. As a result of complex interactions among inflammatory cells, structural cells, and the intercellular matrix of the allergic lung, patients with sensitization to fungal allergens may experience a greater degree of airway wall remodeling and progressive, accumulated pulmonary dysfunction as part of the disease sequela. From their development in the bone marrow to their recruitment to the lung via chemokine and cytokine networks, eosinophils form an important component of the inflammatory milieu that is associated with this syndrome. Eosinophils are recognized as complex multi-factorial leukocytes with diverse functions in the context of allergic fungal asthma. In this review, we will consider recent advances in our understanding of the molecular mechanisms that are associated with eosinophil development and migration to the allergic lung in response to fungal inhalation, along with the eosinophil’s function in the immune response to and the immunopathology attributed to fungus-associated allergic pulmonary disease.

Expression of the cysteinyl leukotriene 1 receptor and glucocorticoid receptor-β in nasal polyps

The objective of this study was to analyze the expression of cysteinyl leukotriene 1 (CysLT1) receptor and glucocorticoid receptors (GRs) in nasal polyps, and to evaluate the relationship between the expression of CysLT1 receptors and that of GRs. Nasal polyps were taken from 32 patients of chronic rhinosinusitis with nasal polyposis. Samples of middle turbinate from seven healthy subjects were used as controls. Specimens were immunohistochemically stained for CysLT1 receptor, GR-α and GR-β receptor, and were quantified in the unit area of the tissues. Numbers of CysLT1 receptor-positive cells were much increased in nasal polyps than in middle turbinate (281 ± 67 vs. 157 ± 85 cells/mm(2), P = .01). There was no significant difference in the numbers of GR-α positive cells between nasal polyps and normal turbinate mucosa. GR-β positive cells were increased in nasal polyps as compared to normal turbinate mucosa (36 ± 8 vs. 19 ± 7 cells/mm(2), P = .03). A significant relationship was found between the expression of CysLT1 receptor and GR-β in nasal polyps (R = .525, P = .04), whereas there was no significant relationship between the expression of CysLT1 receptor and GR-α in nasal polyps. Our study shows that CysLT1 receptor expression predominates on GR-β over-expressed polyps. This may suggest the additional effect of CysLT1 receptor antagonist for the treatment of nasal polyposis resistant to steroid alone.

A dried yeast fermentate prevents and reduces inflammation in two separate experimental immune models

Diverse and significant benefits against cold/flu symptoms and seasonal allergies have been observed with a dried fermentate (DF) derived from Saccharomyces cerevisiae (EpiCor) in multiple published randomized trials. To determine if DF may influence other immune conditions, two separate animal studies were conducted. Study 1 examined the ability of DF to prevent or reduce inflammation when given orally for 14 days to rats prior to receiving 1% carrageenan (localized inflammation model). DF significantly (P < 0.05) reduced swelling at all time points (1, 2, 3, 6, 12, and 24 hours) versus the control. Edema severity and PGE2 levels were reduced by approximately 50% and 25% (P < 0.05), respectively. Study 2 examined the ability of DF to treat established inflammation induced by type-2 collagen in mice over 4 weeks (autoimmune arthritis model). Significantly reduced arthritis scores, antibody response to type-2 collagen, and interferon-gamma levels were observed compared to controls (all parameters P < 0.05). DF favorably impacts multiple acute and potentially chronic immunologic inflammatory control mechanisms and should be further tested in clinical trials.

Nasal endoscopy in children with suspected allergic rhinitis

OBJECTIVES/HYPOTHESIS

Ear, nose, and throat assessment may be frequently requested for children with allergic rhinitis (AR). Nasal endoscopy allows a thorough evaluation of the nose. The aim of the study was to investigate whether there are endoscopic signs predictive for AR diagnosis in a cohort of children with suspected AR.

STUDY DESIGN

Cohort of observational study.

METHODS

There were 176 children (99 males; mean age, 7.5 years) studied. Clinical visit, nasal endoscopy, and skin prick test were performed in all patients. Nasal endoscopic signs were pale turbinates, middle turbinate contact, and inferior turbinate contact. The AR diagnosis was made when nasal symptom history was concordant with sensitization.

RESULTS

AR was diagnosed in 141 children. Inferior and middle turbinate contact were reliable predictive factors for AR (odds ratio 5.38 and 3.42, respectively), whereas pale turbinates did not predict it.

CONCLUSIONS

This study suggests that nasal endoscopy may reveal signs predictive for AR diagnosis in children.

A multicenter randomized double-blind 2-week comparison study of azelastine nasal spray 0.1% versus levocabastine nasal spray 0.05% in patients with moderate-to-severe allergic rhinitis

OBJECTIVE

To compare the onset of action, efficacy, and safety of azelastine and levocabastine in the treatment of allergic rhinitis.

SUBJECTS AND METHODS

In a multicenter, randomized, double-blind, parallel-group trial, 244 patients with moderate-to-severe allergic rhinitis were randomized to receive either azelastine hydrochloride nasal spray (ANS) 0.1% or levocabastine hydrochloride nasal spray (LNS) 0.05% for 14 consecutive days. A visual analog scale was used to record total nasal symptom score (TNSS) changes. Indexes for further assessment included onset of action, total effective rate, and evaluation of therapeutic effect.

RESULTS

Statistically significant changes from baseline in TNSS were seen in both the LNS group and the ANS group. No significant differences were seen between the two groups in terms of evaluation of therapeutic effect, total effective rate, and onset of action, except for a higher symptom relief rate in the LNS group than in the ANS group within 30 min of administering the first dose. Adverse reactions were mild to moderate, with an incidence of 0.9% for LNS and 2.5% for ANS.

CONCLUSION

Both ANS and LNS were effective and safe in the treatment of moderate-to-severe persistent allergic rhinitis. Moreover, LNS reached a higher symptom relief rate within 30 min of administering the first dose.

Synthesis and structure-activity relationship of tricyclic carboxylic acids as novel anti-histamines

A series of tricyclic carboxylic acids having 6-amino-pyrimidine-2,4(1H,3H)-dione with piperazino or homopiperazino moiety linked by propylene, were synthesized and evaluated for their affinity toward human histamine H(1) receptor and Caco-2 cell permeability. Selected compounds were further evaluated for their oral anti-histaminic activity in mice, bioavailability in rats, and their anti-inflammatory activity in mice OVA-induced biphasic cutaneous reaction model. Among the compounds tested, dibenzoxazepine carboxylic acid 13b showed both histamine H(1) receptor antagonistic activity and anti-inflammatory activity in vivo. In addition, 13b exhibited low affinity toward α(1) receptor and low occupancy of H(1) receptor in the brain. It is therefore, believed that 13b is a potential candidate for development as 3rd generation anti-histamine.

Pathological mechanisms and clinical features of eosinophilic chronic rhinosinusitis in the Japanese population

The overall pathological view of paranasal sinus inflammation in the Japanese population has profoundly changed in recent years. Eosinophilic chronic rhinosinusitis (ECRS) is a clinical entity of intractable chronic sinus inflammation accompanied by numerous infiltrations of activated eosinophils in the paranasal sinus mucosa and/or nasal polyps. Several pathologic processes are considered to act in concert to promote the accumulation of eosinophils in ECRS. They include infiltration of progenitor cells, increase in local IL-3, IL-5, IL-13, GM-CSF and eotaxin production, and upregulation of adhesion molecules. The role of nasal allergen sensitization and innate immunity responses in the sinus mucosa has also been proposed in the development of ECRS. Various pathogens including TLRs ligands may trigger an abnormal immune response at the mucosal surface. The objectives of ECRS management should focus directly on inhibition of local eosinophil infiltration. Surgical procedures include widely opening the bony wall septum of every affected sinus and mechanical removal of diseased mucosal lesion. The use of local and/or systemic steroids, leukotriene receptor antagonists, and Th2 cytokine antagonists is recommended. Local administration of steroids is a potent treatment strategy for preventing relapse of nasal polyposis and is considered to be the first-line treatment for ECRS patients.

Impact of allergic rhinitis on asthma in children: effects on bronchodilation test

BACKGROUND

Relevant relationship exists between upper and lower airways. Bronchial obstruction is a paramount feature of asthma and its reversibility is considered a diagnostic step for asthma diagnosis.

OBJECTIVE

This study aimed at evaluating a large group of children with allergic rhinitis alone for investigating the degree of brochodilation and possible factors related to it.

METHODS

Two hundred patients with allergic rhinitis and 150 normal subjects were consecutively evaluated. Clinical examination, skin prick test, spirometry, and bronchodilation test were performed in all patients.

RESULTS

Rhinitics showed a significant FEV(1) increase after bronchodilation test (P < 0.0001) in comparison both to basal values and to controls' levels. More than 20% of rhinitics had reversibility (> or =12% basal levels). Patients with reversibility had lower FEV(1) levels, longer rhinitis duration, and perennial allergy.

CONCLUSION

This study highlights the close link between upper and lower airways and the relevance of performing bronchodilation test in patients with allergic rhinitis and these characteristics.

Relationship between Responses to Bronchodilation Testing and to Nasal Decongestion Testing in Patients with Allergic Rhinitis Alone

A remarkable relationship exists between upper and lower airways. Bronchial obstruction is a paramount feature of asthma as well as nasal obstruction of allergic rhinitis (AR). This study aims to evaluate the response to both bronchodilation and decongestion testing and their relationships in a large group of patients with moderate-severe persistent AR alone. Two hundred eleven patients with moderate-severe persistent AR were prospectively and consecutively evaluated. Clinical examination, skin prick test, spirometry, bronchodilation test, rhinomanometry, and decongestion test were performed on all patients. Seventeen subjects (8%) did not respond to any of the tests, 55 subjects (26.1%) were responders only to the decongestion test, 31 (14.7%) only to the bronchodilation test, and 108 subjects (51.2%) responded to both these tests. Longer AR duration was significantly associated with positive response to both tests (p<0.01). In conclusion, this study provides the first evidence that patients with moderate-severe persistent AR may frequently show reversibility to both bronchodilation and decongestion tests.

Impact of allergic rhinitis on asthma: effects on bronchial hyperreactivity

BACKGROUND

Remarkable relationship exists between upper and lower airways. Bronchial hyperreactivity (BHR) is a paramount feature of asthma and may be considered a strong risk factor for the onset of asthma in patients with allergic rhinitis.

OBJECTIVE

This study is aimed at evaluating the presence of BHR in a large group of patients with moderate-severe persistent allergic rhinitis alone, and at investigating possible risk factors related to severe BHR.

METHODS

Three hundred and forty-two patients with moderate-severe persistent allergic rhinitis were prospectively and consecutively evaluated. Clinical examination, skin prick test, spirometry and bronchial methacholine (MCH) test were performed in all patients.

RESULTS

Twenty-two (6.4%) patients had severe BHR, 74 (21.6%) patients had mild BHR and 192 (56.2%) had borderline BHR; 54 (15.8%) patients had a negative MCH test. The logistic regression analysis evidenced that trees and house dust mites sensitization (ORAdj: 8.1), rhinitis duration > 5 years (ORAdj: 5.4) and FEV1 < or = 86% of predicted (ORAdj: 4.0) were significantly associated with severe BHR. The discriminative ability of this model is appreciably satisfactory, being the AUC = 0.90.

CONCLUSION

This study highlights the close link between upper and lower airways and the role of some risk factors, such as tree and mite sensitization, > 5-year duration, and < or = 86% FEV1 values, as risk factors for severe BHR in patients with moderate-severe persistent allergic rhinitis alone. Therefore, BHR is frequently present in patients with chronic rhinitis and should be suspected in the presence of defined risk factors.

Levocetirizine modulates lymphocyte activation in patients with allergic rhinitis

Levocetirizine, a second generation non-sedating antihistamine that blocks the H(1) histamine receptor, may exhibit immunoregulatory properties that augment its primary pharmacological mechanism. To investigate this possibility, 13 Kuwaiti seasonal allergic rhinitis (SAR) patients were treated with levocetirizine for four weeks in comparison with a 7-member placebo-treated control group, followed by clinical evaluation and flow cytometric analysis of peripheral venous blood for inflammatory cell and lymphocyte subpopulation profiles. Relative to the controls, levocetirizine-treated patients exhibited an expected reduction in early phase allergic symptoms, including sneezing (P<0.001), nasal itching (P<0.01), nasal congestion, and running nose (P<0.001); reduced percentages of eosinophils (P<0.05); and three subpopulations of activated T lymphocytes: CD4+CD29+, CD4+CD212+, and CD4+CD54+ (P<0.05). Levocetirizine treatment also correlated with a significant increase in the percentage of CD4+CD25+ T cells (P<0.001). The ability of levocetirizine to reduce percentage representation of cell phenotypes known to contribute to inflammatory tissue damage (eosinophils, CD4+CD29+, CD4+CD212+, and CD4+CD54+) and expand percentages of CD4+CD25+, which may include protective immunoregulatory (Treg) cells, indicates that the drug has pharmacological potential beyond the immediate effects of H(1) histamine-receptor inhibition. Although the present data does not define a therapeutic mechanism, the results reported here establish important trends that may be used to guide future mechanistic examination of immunoregulatory capacity of H(1) inhibitors.

Prostaglandin E receptor subtype EP3 in conjunctival epithelium regulates late-phase reaction of experimental allergic conjunctivitis

BACKGROUND

We previously demonstrated that the prostaglandin E(2) (PGE(2))-EP3 pathway negatively regulates allergic reactions in a murine allergic asthma model.

OBJECTIVES

We investigated whether the PGE(2)-EP3 pathway also regulates the development of murine experimental allergic conjunctivitis (EAC).

METHODS

The expression of EP3 was examined by means of RT-PCR and immunohistochemistry in wild-type mice, as well as by means of 5-bromo-4-chloro-3-indolyl-beta-D-galactopyranoside staining in mice deficient in EP3 (Ptger3(-/-) mice) carrying the beta-galactosidase gene at the EP3 gene locus. EAC was induced by immunization of mice with short ragweed pollen (RW), followed by challenge with eye drops of RW, and eosinophil infiltration and eotaxin-1 mRNA expression in the conjunctiva were examined. Mice were also treated with a topical application of an EP3-selective agonist during the elicitation phase. Quantitative RT-PCR was used to detect expression of COXs and prostaglandin E synthases, and ELISA was used to measure PGE(2) production in the eyelid.

RESULTS

EP3 was constitutively expressed in conjunctival epithelium on the ocular surface. Ptger3(-/-) mice demonstrated significantly increased eosinophil infiltration in conjunctiva after RW challenge compared with wild-type mice. Consistently, significantly higher expression of eotaxin-1 mRNA was observed in Ptger3(-/-) mice. Conversely, treatment of wild-type mice with an EP3-selective agonist resulted in a significant decrease in eosinophil infiltration, which was blunted in Ptger3(-/-) mice. Expression of COX-2 and prostaglandin E synthases was upregulated and PGE(2) content was increased in the eyelids after RW challenge.

CONCLUSION

These data suggest that PGE(2) acts on EP3 in conjunctival epithelium and downregulates the progression of EAC.

Impact of allergic rhinitis on asthma: effects on bronchodilation testing

BACKGROUND

A remarkable relationship exists between the upper and lower airways. Bronchial obstruction is a paramount feature of asthma, and its reversibility is considered a main step in asthma diagnosis.

OBJECTIVE

To investigate the degree of bronchodilation and possible risk factors related to it in patients with moderate-severe persistent allergic rhinitis alone.

METHODS

A total of 375 patients with moderate-severe persistent allergic rhinitis and 115 controls were prospectively and consecutively evaluated by means of clinical examination, skin prick testing, spirometry, and bronchodilation testing.

RESULTS

Patients with rhinitis showed a significant increase in forced expiratory volume in 1 second (FEV) after bronchodilation testing compared with basal values and levels in controls (P < .001). Two-thirds of the rhinitic patients had reversibility (> or = 12% basal levels). Patients with reversibility had lower FEV1 levels, longer rhinitis duration, and mite and tree allergies.

CONCLUSIONS

This study highlights the close link between the upper and lower airways and the relevance of performing bronchodilation testing in patients with moderate-severe persistent allergic rhinitis.

Role of hypoxia in inflammatory upper airway disease

PURPOSE OF REVIEW

Hypoxia is a potent stimulus for inflammation and remodeling. Hypoxia develops in chronic sinusitis as shown via tissue oxygen concentrations and colonization with obligate anaerobes. This hypoxia reflects occlusion of the sinus ostia and thereby failure of transepithelial oxygenation, nonvascularized exudates, and the tendency of inflammatory hyperplasia to exceed neovascularization.

RECENT FINDINGS

Hypoxia-induced transcription factors are responsible for transcription of numerous inflammatory cytokines and growth factors, including vascular endothelial growth factor, CXCL8, CCL11, transforming growth factor-beta, inducible nitric oxide synthase, as well as matrix remodeling proteins such as procollagen and matrix metalloproteinases.

SUMMARY

Many diseases, such as asthma, share the tendency to afflict respiratory epithelium of the lower (bronchi) and upper (sinus) airway. Although the histopathology and inflammation of asthma and its associated sinusitis share many features, aggressive fibrosis, polyp formation and intense hyperplasia are not features of asthma, a disease seldom associated with significant chronic hypoxia. In contrast, fibrosis is a cardinal feature of hypoxic diseases of the lungs such as interstitial lung diseases and primary pulmonary hypertension. Arguably, chronic sinusitis can be viewed as reflecting both 'asthma' and 'primary pulmonary hypertension' of the upper airway.

Allergic rhinitis and rhinosinusitis

A relationship between allergic rhinitis and acute and chronic rhinosinusitis has been postulated for many years. Epidemiologic evidence suggests that such a relationship is likely. In addition, evidence of a common pathophysiologic mechanism linking these diseases is compelling and continues to evolve. Although a clear and definitive causal relationship remains to be elucidated, an increasing number of studies support the plausibility of this link. The current paradigm of the "unified airway" and evidence to support this model further strengthen this link. This article reviews the literature relating allergic rhinitis and acute and chronic rhinosinusitis.