Comparison of nasal responsiveness to histamine, methacholine and phentolamine in allergic rhinitis patients and controls

Suppressive Effect of Lactococcus lactis subsp. cremoris YRC3780 on a Murine Model of Japanese Cedar Pollinosis

Accumulating evidence suggests that Lactococcus lactis subsp. cremoris YRC3780 isolated from kefir has the potential to alleviate allergic responses. Herein, we investigated the effect of YRC3780 on a murine model of Japanese cedar pollinosis (JCP). BALB/c mice immunized with cedar pollen extract (CPE) exhibited an increase in serum immunoglobulin E and developed nasal inflammatory responses including sneezing, nasal hyperresponsiveness, and nasal eosinophil accumulation upon intranasal allergen challenge. These responses were suppressed by the oral administration of YRC3780, although the effects on CPE-induced sneezing response and eosinophil infiltration were not statistically significant. Total fecal microbiota diversity was not affected by allergen immunization and challenge or by YRC3780 administration. However, the abundances of Bifidobacteriales, Veillonellaceae, Lactococcus, and Lactococcus lactis were larger and that of Bacteroides was smaller in YRC3780-treated mice compared with those in CPE-challenged and YRC3780-untreated mice. Our findings suggest the usefulness of YRC3780 for alleviating JCP.

Thresholds in Nasal Histamine Challenge in Patients with Allergic Rhinitis, Patients with Hyperreflectory Rhinopathy, and Healthy Volunteers

Background

Characteristic symptoms of hyperreflectory rhinopathy include recurrent sneezing, nasal obstruction, and nasal secretion without an allergic background. The diagnosis can only be made if all differential diagnoses have been excluded. So far no clinical test has been established to reliably diagnose hyperreactivity of the nasal mucosa. The present study aimed to investigate whether nasal provocation with histamine allows identification of patients with hyperreflectory rhinopathy.

Materials and Methods

One-sided nasal challenge with histamine was applied to 13 patients with allergic rhinitis, 13 patients with hyperreflectory rhinitis, and 12 healthy volunteers. Histamine concentrations used were 0.25, 0.5, 1.0, 2.0, 4.0, 8.0, and 16.0 mg/mL. Test results were quantified using a symptom score (positive at values above 3) and active anterior rhinomanometry (positive at a reduction of airflow of 40% or more in comparison to challenge with solvent).

Results

While there was a significant difference between controls and patients with allergic rhinitis or hyperreflectory rhinopathy, respectively, no significant difference was observed between the two groups of patients. Results indicated that one-sided nasal provocation with histamine at a concentration of 1 mg/mL is sufficient to separate healthy subjects from patients with hyperreactivity of the nasal mucosa. In terms of the differentiation between subjects with hyperreactivity of the nasal mucosa and healthy controls, the sensitivity of one-sided nasal histamine provocation with 1 mg/mL was found to be 100%; its specificity was 83% if it was evaluated by rhinomanometry and symptom score.

Conclusion

The present results indicate that one-sided nasal challenge with histamine at a concentration of 1 mg/mL is sufficient to separate healthy subjects from patients with hyperreactivity of the nasal mucosa. However, the test does not differentiate between patients with allergic rhinitis and patients with hyperreflectory rhinitis.

Effect of Experimental Influenza A Infection on the Nasal Response to Histamine Challenge in Allergic and Non-Allergic Subjects

To determine if a viral upper respiratory tract infection can alter the responsiveness of the nasal mucosa, paired intranasal histamine challenge sessions were performed before and after (8 days) intranasal inoculation with influenza A virus in 16 nonallergic and 16 allergic subjects. The nasal response to a 1-mg histamine challenge was measured as symptom scores for rhinorrhea and congestion, counts for sneezing, weight for expelled secretions, and inspiratory conductance for nasal patency. After inoculation, a total of 25 subjects (11 allergic, 14 nonallergic) became infected with influenza A virus. In infected subjects the measured responses to histamine for secretion weight and rhinorrhea symptom score were significantly greater at 8 days postinfection when compared to those responses recorded prior to inoculation. No significant between session differences were observed for the other responses, or for any of the responses in the uninfected subjects. Significant differences between infected allergic and nonallergic subjects were not observed for any response. These results document an increased secretory response of the nose to histamine during the postsymptomatic period of influenza A viral infection in both allergic and nonallergic subjects.

Essential Contribution of CD4+ T Cells to Antigen-Induced Nasal Hyperresponsiveness in Experimental Allergic Rhinitis

Nasal hyperresponsiveness (NHR) is a characteristic feature of allergic rhinitis (AR); however, the pathogenesis of NHR is not fully understood. In this study, during the establishment of an experimental AR model using ovalbumin-immunized and -challenged mice, augmentation of the sneezing reaction in response to nonspecific proteins as well as a chemical stimulant was detected. Whether NHR is independent of mast cells and eosinophils was determined by using mast cell- and eosinophil-deficient mice. NHR was suppressed by treatment with anti-CD4 antibody, suggesting the pivotal contribution of CD4+ T cells. Furthermore, antigen challenge to mice to which in vitro-differentiated Th1, Th2, and Th17 cells but not naïve CD4+ T cells had been adoptively transferred led to the development of equivalent NHR. Since antigen-specific IgE and IgG were not produced in these mice and since antigen-specific IgE-transgenic mice did not develop NHR even upon antigen challenge, humoral immunity would be dispensable for NHR. CD4+ T cells play a crucial role in the pathogenesis of AR via induction of NHR, independent of IgE-, mast cell-, and eosinophil-mediated responses.

Nasal hyperreactivity and inflammation in allergic rhinitis

The history of allergic disease goes back to 1819, when Bostock described his own 'periodical affection of the eyes and chest', which he called 'summer catarrh'. Since they thought it was produced by the effluvium of new hay, this condition was also called hay fever. Later, in 1873, Blackley established that pollen played an important role in the causation of hay fever. Nowadays, the definition of allergy is 'An untoward physiologic event mediated by a variety of different immunologic reactions'. In this review, the term allergy will be restricted to the IgE-dependent reactions. The most important clinical manifestations of IgE-dependent reactions are allergic conjunctivitis, allergic rhinitis, allergic asthma and atopic dermatitis. However, this review will be restricted to allergic rhinitis. The histopathological features of allergic inflammation involve an increase in blood flow and vascular permeability, leading to plasma exudation and the formation of oedema. In addition, a cascade of events occurs which involves a variety of inflammatory cells. These inflammatory cells migrate under the influence of chemotactic agents to the site of injury and induce the process of repair. Several types of inflammatory cells have been implicated in the pathogenesis of allergic rhinitis. After specific or nonspecific stimuli, inflammatory mediators are generated from cells normally found in the nose, such as mast cells, antigen-presenting cells and epithelial cells (primary effector cells) and from cells recruited into the nose, such as basophils, eosinophils, lymphocytes, platelets and neutrophils (secondary effector cells). This review describes the identification of each of the inflammatory cells and their mediators which play a role in the perennial allergic processes in the nose of rhinitis patients.

Objective improvement in nasal congestion and nasal hyperreactivity with use of nasal steroids in persistent allergic rhinitis

OBJECTIVE

Our objective was to evaluate the action of topical nasal steroid in nasal congestion and nasal hyper-reactivity in children and adolescents with persistent allergic rhinitis.

METHODS

Twenty atopic children and adolescents (6 to 18 years) with moderate-to-severe persistent allergic rhinitis (PAR) were treated with mometasone furoate (100 microg once a day) for 21 days. At the beginning and end of treatment, the following were recorded: a) nasal symptoms score; b) several parameters of nasal congestion measured by acoustic rhinometry (SRE 2000 Rhinometrics); c) degree of nasal hyper-reactivity to histamine (concentration of histamine necessary to induce at least 100% increase in total nasal resistance during nasal provocation test). Data were compared with those from 20 controls.

RESULTS

Compared to controls, PAR patients had significantly higher score of symptoms, as well as higher degree of nasal hyper-reactivity and lower nasal volumes. After treatment, there was a significant decrease in the mean nasal symptoms score (8.0 versus 3.8; p < 0.001) and in the nasal hyper-reactivity (histamine concentration: 0.72 mg/ml versus 2.60 mg/ml; p < 0.001). Congestion improvement was observed by the increase in all acoustic rhinometry parameters. Among all studied volumes, the volume in the segment between 2 and 5 cm showed the highest mean increase (19.8%).

CONCLUSION

Treatment with topical nasal steroid objectively reduced nasal congestion and nasal histamine hyper-reactivity in children and adolescents with PAR.

Mechanisms of the cough associated with rhinosinusitis

The diseases of the nose and paranasal sinuses (rhinosinusitis) often in combination with asthma and gastroesophageal reflux are common causes of chronic cough in patients with normal chest radiograph. The relationships between rhinosinusitis and cough are incompletely understood. We investigated modulation of the cough reflex by the inputs from the nose. We demonstrate that the cough reflex is sensitized by the intranasal administration of sensory nerve activators in animal models and in humans. Cough reflex is also sensitized in the guinea pig model of allergic nasal inflammation and in patients with allergic rhinitis. In patients with allergic rhinitis the cough sensitization is augmented during the allergen season. We conclude that the cough reflex can be sensitized from the nose. Our data indicate that this sensitization is mediated by nasal sensory nerves. We speculate that by inducing the cough reflex sensitization rhinosinusitis contributes to chronic cough. If combined with environmental or endogenous cough triggers, the cough reflex sensitization is predicted to cause excessive coughing. The potential endogenous cough triggers may be associated with rhinosinusitis (postnasal drip, aspiration of nasal secrets) or secondary to a coexistent disease such as asthma or gastroesophageal reflux.

Objective monitoring of nasal patency and nasal physiology in rhinitis

Nasal obstruction can be monitored objectively by measurement of nasal airflow, as evaluated by nasal peak flow, or as airways resistance/conductance as evaluated by rhinomanometry. Peak flow can be measured during inspiration or expiration. Of these measurements, nasal inspiratory peak flow is the best validated technique for home monitoring in clinical trials. The equipment is portable, relatively inexpensive, and simple to use. One disadvantage, however, is that nasal inspiratory peak flow is influenced by lower airway as well as upper airway function. Rhinomanometry is a more sensitive technique that is specific for nasal measurements. The equipment, however, requires an operator, is more expensive, and is not portable. Thus, it is applicable only for clinic visit measures in clinical trials. Measurements require patient cooperation and coordination, and not all can achieve repeatable results. Thus, this objective measure is best suited to laboratory challenge studies involving smaller numbers of selected volunteers. A nonphysiological measure of nasal patency is acoustic rhinometry. This sonic echo technique measures internal nasal luminal volume and the minimum cross-sectional area. The derivation of these measures from the reflected sound waves requires complex mathematical transformation and makes several theoretical assumptions. Despite this, however, such measures correlate well with the nasal physiological measures, and the nasal volume measures have been shown to relate well to results obtained by imaging techniques such as computed tomography scanning or magnetic resonance imaging. Like rhinomanometry, acoustic rhinometry is not suitable for home monitoring and can be applied only to clinic visit measures or for laboratory nasal challenge monitoring. It has advantages in being easy to use, in requiring little patient cooperation, and in providing repeatable results. In addition to nasal obstruction, allergic rhinitis is recognized to be associated with impaired mucociliary clearance and altered nasal responsiveness. Measures exist for the monitoring of these aspects of nasal dysfunction. Although measures of mucociliary clearance are simple to perform, they have a poor record of reproducibility. Their incorporation into clinical trials is thus questionable, although positive outcomes from therapeutic intervention have been reported. Measures of nasal responsiveness are at present largely confined to research studies investigating disease mechanisms in allergic and nonallergic rhinitis. The techniques are insufficiently standardized to be applied to multicenter clinical trials but could be used in limited-center studies to gain insight into the regulatory effects of different therapeutic modalities.

Lower respiratory tract complications during nasal provocation: nonspecific stimulant or specific allergen?

BACKGROUND

Allergic rhinitis (AR) is an allergic inflammatory disease in which allergen exposure leads to the appearance of symptoms in sensitized individuals because of histamine liberation from nasal mucosal mast cells. Comorbidity of this disease with allergic asthma is common. Therefore, the one airway one disease theory has been put forward. Lower respiratory tract provocation tests with both nonspecific (methacholine) and specific stimulants (allergen) have yielded positive results in nonasthmatic patients with AR. However, not enough research is available to demonstrate whether there is a response in the lower respiratory tract during nasal provocation tests (NPTs) performed to evaluate only nasal airway in these patients.

OBJECTIVES

To determine if the lower respiratory tract was affected as a result of NPTs with nonspecific and specific stimulants in nonasthmatic patients with AR and to determine the frequency of lower respiratory tract obstruction due to NPT with nonspecific and specific stimulants.

METHODS

Thirty-six participants were enrolled in the study between November 2005 and January 2006 (18 AR patients and 18 healthy control subjects). Patients underwent 2 sessions of NPT. The first session was performed with nasal methacholine as a nonspecific stimulant, and the second session was performed with nasal Olea europaea extract as a specific stimulant. The control group underwent only nonspecific nasal provocation with methacholine. Basal nasal opening and nasal pressures were evaluated spirometrically by rhinomanometric measurements and basal respiratory function tests in both groups before methacholine nasal provocation. Whether or not nasal provocation was achieved, spirometric measurements were performed in all patients and controls after NPTs.

RESULTS

NPTs with methacholine resulted in a similar frequency of nasal provocation in the patient and control groups (P = .63). However, the mean methacholine dose was lower in patients with AR (P = .049). There was a decrease in parameters of asthma, including the ratio of forced expiratory volume in 1 second to forced vital capacity (P = .04), peak expiratory flow (P = .01), and forced expiratory flow between 25% and 75% (P = .004), as a result of NPTs with methacholine in the patient group. However, NPTs with allergen did not cause a change in lower respiratory tract obstruction criteria.

CONCLUSIONS

Lower respiratory tract obstruction can occur after NPTs with nonspecific stimulants; therefore, tests performed with specific allergens can be regarded as safer.

H1-receptors: localization and role in airway physiology and in immune functions

Histamine H(1)-receptors are involved in the pathologic processes of allergy. Clinical trials of H(1)-receptor antagonists have demonstrated the efficacy of these agents in reducing the sneezing, pruritus, and rhinorrhea associated with allergic rhinitis. In the lung, H(1)-receptors mediate the bronchoconstrictive effects of histamine and increase vascular permeability, which lead to plasma exudation. H(1)-receptors are present on T cells, B cells, monocytes, and lymphocytes, and stimulation of these receptors induces pro-inflammatory effects. It has been suggested that a signal from the H(1)-receptor contributes to the antigen receptor-mediated signaling pathways that induce proliferative responses and lead to the production of cytokines and antibodies by T cells and B cells, respectively. It would appear, therefore, that the H(1)-receptor has a wider role in inflammatory processes than simply mediating the actions of histamine.

Mode of action of intranasal corticosteroids

The mode of action of intranasal corticosteroids (INCS) is complex. It is not known whether INCS penetrate the nasal mucosa or act on target cells; however, their low systemic activity supports the concept of local action on nasal mucosa. This local effect can nonetheless influence a variety of inflammatory cells and their mediators such as epithelial cells, lymphocytes, basophils, mast cells, and Langerhans cells. Corticosteroid-induced inhibition of immunoglobulin E-dependent release of histamine is a possible but unproven mode of action. Epithelial cells are an important target for corticosteroids, and INCS concentration is high at the epithelial surface. INCS may combine with the corticosteroid receptors in epithelial cells, which are then expelled into the airway lumen together with the dead epithelial cells or migrating inflammatory cells. A reduced influx of mediator cells may explain some of the effects of INCS on rhinitis symptoms, but it cannot explain all of the effects because INCS also reduce the early-phase sneezing and rhinorrhea after an allergen challenge outside the pollen season. In this situation, the number of surface mast cells/basophils is very low, as it is in the absence of allergic rhinitis. The mechanism by which INCS treatment of allergic rhinitis reduces itching, sneezing, and rhinorrhea, the characteristic symptoms of an early-phase response involving mast cell release of histamine, remains to be determined. Studies should be conducted to characterize the broad range of mechanisms by which INCS produce their therapeutic effects in allergic rhinitis.

Nasal histamine reactivity; relationships to skin-test responses, allergen provocation and symptom severity in patients with long-continuing allergic rhinitis

It has been reported that skin-test reactivity and rhinitis symptom severity weaken in the course of time. A corresponding weakening might also be seen in non-specific nasal hyper-reactivity, but the relationships of these responses are poorly understood. Our aim was to measure nasal responsiveness to histamine in a series of patients with long-continuing allergic rhinitis and to compare these measurements with skin test responses, allergen provocation and changes in severity of allergic rhinitis symptoms. A total of 73 patients in whom allergic rhinitis had been verified over 20 years earlier were re-interviewed and re-investigated. Skin prick tests with common allergens were performed and the presence of nasal allergy was confirmed by allergen provocation. Non-specific nasal hyper-reactivity was determined with nasal histamine challenge using four concentrations of histamine phosphate. The response was registered by counting sneezes, recording changes in nasal discharge and mucosal swelling and measuring nasal airway resistance. Sneezing and discharge scores showed that milder non-specific nasal hyper-reactivity was associated with lack of reactivity in skin prick tests and nasal allergen challenge. No association was observed between allergy test results and changes in nasal airway resistance during the histamine provocation. In most patients the symptoms of rhinitis had become milder or disappeared during the follow-up, but the results of the histamine challenge showed no relationship with the changes in symptom severity. In patients with allergic rhinitis, reactivity to histamine is associated with a concomitant change in skin and nasal mucosal reactivity to allergens.

Nasal challenge with histamine decreases nonspecific bronchial reactivity in workers exposed to respiratory irritants

BACKGROUND

A link ("naso-bronchial reflex") between nasal and bronchial reactivity seems to exist. The effect of nonspecific nasal challenge (standing for the exposure to irritative stimuli at the workplace) on lung function indices and nonspecific bronchial reactivity is not known.

METHODS

In 80 healthy workers (age: 36.0 +/- 8.6 years) continuously exposed to acceptable levels of different respiratory irritants (for more than 2 years) nasal challenge was performed by spraying doubling concentrations of histamine (0.0625-16.0 mg/mL, doses of histamine: 7.8 micrograms-2.08 mg) into each nostril. Before and immediately after nasal challenge spirometry and the bronchoprovocation test with histamine (0.5-128 mg/mL) was performed.

RESULTS

Although nasal challenge with histamine had not reduced airway caliber (before nasal challenge vs. following nasal challenge: FEV1 3.8 +/- 0.8 vs. 3.7 +/- 0.8 L, and MEF50 4.3 +/- 1.4 vs. 4.3 +/- 1.4 L/s, mean +/- SD, respectively), it had significantly reduced nonspecific bronchial reactivity in 30.2% of the irritant-exposed subjects.

CONCLUSIONS

Nasal challenge with histamine decreases nonspecific bronchial reactivity in workers occupationally exposed to respiratory irritants. Thus, a methodological implication would be that these two tests should not be performed consecutively in less than 2 hr in the same subjects.

Hyperosmolar saline induces reflex nasal secretions, evincing neural hyperresponsiveness in allergic rhinitis

We investigated whether hyperosmolar saline (HS), applied via paper disk onto the septum of one nostril, induces a nasal secretory response. Furthermore, we examined whether this response is accentuated in patients with active allergic rhinitis (AR) compared with healthy volunteers. Unilateral HS produced significant nasal secretions both ipsilateral and contralateral to the site of challenge in the AR group and only ipsilaterally in the healthy group. The HS-induced nasal secretions were significantly greater in the AR vs. the healthy subjects. In a separate study, we ascertained that the nasal response to HS is neurally mediated and found that ipsilateral nerve blockade with lidocaine significantly attenuates the HS-induced secretions bilaterally. In another group of AR subjects, we determined whether nociceptive fibers were involved in this response and found that sensory nerve desensitization with repeated application of capsaicin attenuated the HS-induced nasal secretions. Finally, we determined whether the secretory hyperresponsiveness in AR is attributable to increased reactivity of submucosal glands rather than of nerves. We found that the dose response to methacholine, which directly stimulates the glands, was identical among AR and healthy subjects. We conclude that, in AR, nasal challenge with HS induces significantly greater reflex secretions involving capsaicin-sensitive nerve fibers, consistent with the notion of neural hyperresponsiveness in this disease.

Non-specific nasal and bronchial reactivity are not correlated in non-asthmatic subjects occupationally exposed to irritants and in healthy subjects

BACKGROUND

Non-specific nasal and bronchial reactivity are frequently correlated in disease (rhinitis and asthma). It is not known whether such a correlation exists in subjects exposed to irritants and in healthy subjects. In order to test the hypothesis that a correlation between non-specific nasal and bronchial reactivity exists in non-asthmatic subjects, two groups of subjects were studied: 110 workers occupationally exposed to respiratory irritants, and 86 non-exposed healthy controls.

METHODS

Allergy, non-specific nasal, and non-specific bronchial reactivity were tested, and smoking habits were categorized in each subject.

RESULTS

Respiratory irritants cause a substantial increase in nasal and bronchial reactivity when compared with the group of healthy, non-exposed subjects (33.6% nasal hyperreactors and 20.0% bronchial hyperreactors vs. 4.7% nasal hyperreactors and 2.3% bronchial hyperreactors, respectively). But, occupational exposure to respiratory irritants does not induce a correlation between non-specific nasal and bronchial reactivity frequently found in asthmatic and rhinitic subjects.

CONCLUSIONS

We found no correlation between non-specific nasal and bronchial reactivity either in subjects occupationally exposed to respiratory irritants or in the group of healthy subjects. This lack of correlation in both studied groups seems to be a feature of non-diseased airways. Smoking as an additional factor does not increase nasal and bronchial reactivity either in workers exposed to irritants or in healthy subjects. Smoking also does not strengthen the correlation between upper and lower airways' reactivity in both groups.

Nasal and bronchial histamine reactivity in patients with allergic rhinitis out of season

BACKGROUND

The correlation between non-specific hyperreactivity of upper and lower airways in pathologic conditions has not been studied extensively.

OBJECTIVE

To investigate the occurrence of nasal and bronchial hyperreactivity in patients with allergic rhinitis studied out-of-season.

METHODS

From patients admitted to the Allergy Unit at Stockholm Söder Hospital, 12 individuals with allergic rhinitis due to grass or birch pollen were selected. The nasal mucosa was exposed to increasing concentrations of histamine chloride and the response was recorded by rhinostereometry, an optical method that exclusively measures changes in nasal congestion. Bronchial histamine challenge was performed in connection with the nasal tests, but on different days.

RESULTS

The nasal histamine response was significantly greater than in a reference group of healthy volunteers (P < .01). Nasal hyperreactivity was demonstrated in 9 of 12 patients. No clear relation between the magnitude of nasal and bronchial histamine responses was seen in the study group.

CONCLUSIONS

In allergic rhinitis studied out-of-season, airway hyperreactivity is common in both upper and lower airways, but does not necessarily occur together in the same individual.

Nasal passage patency in patients with allergic rhinitis measured by acoustic rhinometry: nasal responses after allergen and histamine provocation

We investigated nasal passage patency after allergen and histamine provocation in patients with allergic rhinitis by acoustic rhinometry. In total, 75 outpatients with allergic rhinitis were studied. The threshold of nasal hypersensitivity to histamine was measured by the 10 microliters instillation of serial 10-fold dilution in the ipsilateral nasal cavity. Nasal provocation testing to specific antigen was applied to the anterior part of inferior turbinate in bilateral sides in sitting position. Measurement of nasal patency by acoustic rhinometry was repeated three times in each nasal cavity. The minimal cross-sectional area and total volume of nasal cavity were measured in an individual subject. The minimal cross-sectional area and total volume in the histamine challenged-side significantly decreased on the 10(-2), 10(-1), 10(-0) of end point, and up to 30 min after challenge with the threshold dose, but not in the unchallenged side. This means acoustic reflection technique is sensitive at least 100-fold in comparison with classical method like findings by anterior rhinoscopy and symptom scores. Nasal passage patency after bilateral allergen provocation showed predominant in the unilateral side, suggesting the cross over-reflex effects. It was concluded that acoustic rhinometry is one of the highly quantitative and sensitive method which can observe the change of nasal congestion.

Efficacy and onset of action of fluticasone propionate aqueous nasal spray on nasal symptoms, eosinophil count, and mediator release after nasal allergen challenge in patients with seasonal allergic rhinitis

We studied the effect and onset of action of fluticasone propionate aqueous nasal spray (FPANS) on mediator release and eosinophil accumulation in nasal secretions and on nasal symptoms of patients with seasonal allergic rhinitis after nasal allergen challenge (NAC). At the end of the pollen season, 28 patients were randomized in a double-blind and crossover design to receive 7 days' treatment with FPANS (200 microg, once daily) and matching placebo. NACs were performed before and at 6 h and 1, 2, 3, and 7 days during treatment with FPANS or placebo. Nasal secretions were collected for a quantitative determination of mediators and eosinophil count before and 5 min after each challenge. Nasal symptoms were assessed by scales grading the severity of symptoms at the same time. Results showed that for mediator concentrations there was a significant decrease of leukotriene C4 (P<0.001) at 7 days after the first administration of FPANS as compared to placebo. Two days after FPANS, both eosinophil counts and eosinophil cationic protein (ECP) concentrations were lower than those of placebo (eosinophils: P=0.032; ECP: P=0.038). The onset became even more important at day 7 (eosinophils: P=0.001; ECP: P=0.009) during the FPANS treatment period. For the subjective nasal symptoms, a significant reduction of symptom scores for nasal obstruction occurred also at day 3 (P=0.017) and for sneezing at day 7 (P=0.003). There was not yet any significant improvement of the objective nasal airway resistance after the different NACs during the study period. In conclusion, this study demonstrated that topical fluticasone propionate is effective in the treatment of mucosal inflammation induced by NAC. For optimal control of nasal symptoms induced by repeated maximal allergen challenges, a treatment period of more than 1 week is required.

An approach to the understanding of the nasal early-phase reaction induced by nasal allergen challenge

Quantitative determinations of the inflammatory mediators in nasal secretions were performed and correlated with the objective nasal symptoms within 1 h after nasal allergen challenge (NAC). Twenty-six patients with seasonal allergic rhinitis were enrolled outside the pollen season. All measurements were performed before (as a baseline control) and at 1, 5, 10, 30, and 60 min after NAC. This study aimed to clarify the pathogenic mechanism of the early-phase reaction (EPR) by monitoring the evolution of early-phase mediators in nasal secretions and the presence of nasal symptoms during this period. The results showed that, after NAC, the maximal mediator concentration was already reached after 1 min for histamine (124 ng/g), 5 min for tryptase (56 microU/g), and 5-10 min for leukotriene C4 (40 ng/g). Itching and sneezing started as early as 20-30 s, and they were predominant symptoms within 5 min. Rhinorrhea and nasal obstruction started a few minutes after NAC and lasted until more than 1 h after NAC. There was no significant correlation between any single mediator and nasal symptoms during the sampling period. In conclusion, this study demonstrated that during the EPR the presence of nasal symptoms involves a complex mechanism, reflecting the interaction between the mediators released by inflammatory cells, and the receptors on different target organs. When evaluating symptoms during the EPR, one must consider not only the severity of these symptoms but also the time period within which these symptoms occur. For the symptoms of nasal obstruction and rhinorrhea, the early-phase reaction often lasted more than 1 h.

The link between the nose and lung, perennial rhinitis and asthma--is it the same disease?

Perennial rhinitis and asthma are clinical syndromes representing a range of overlapping pathologies; accurate classification should therefore precede any comparison. Although the sinonasal cavities, trachea and bronchi have a common respiratory mucosa, there are also anatomical differences. For example, the nose has a capacitance vessel network and the lower airways possess smooth muscle, both of which are responsive to neurohumoral influences. The prevalence of rhinitis and asthma has increased over the last three decades. Rhinitis occurs in around 75% of allergic asthmatics while 20% of perennial allergic rhinitics develop asthma. Eosinophils, and their associated proteins and cytokines, may play a central role in both perennial rhinitis and asthma with and without atopy. The characteristic pathology of asthma can be summarized as a chronic, desquamating, eosinophilic bronchitis. Non-allergic rhinitis with eosinophilia is recognized, but without consistent evidence of epithelial damage. Eosinophils are also present in rhinosinusitis with polyposis, particularly in patients with aspirin sensitivity, in whom asthma also often occurs. Increased mast cell activation and mediator release is evident in both perennial rhinitis and asthma following allergen challenge. The importance of mast cells in non-atopic asthma and polyposis is also recognized. Adhesion molecules may also be upregulated, with an increased number and activation of TH2 lymphocytes. However, allergen-resultant T-cell activation may be less marked in the nose than in the lung. Autonomic imbalance also plays a role in both conditions via changes in neural tone to effector tissues, release of neuropeptides, and interplay with cellular recruitment. Pharmacological manipulation of rhinitis and asthma also illustrates the pathological similarities and differences.

Effect of H1 and H2 antagonists on nasal symptoms and mediator release in atopic patients after nasal allergen challenge during the pollen season

During the pollen season, quantitative determination of the chemical mediators and eosinophil count was performed in 16 patients with hay fever after nasal allergen challenge (NAC). The aim of this study was objectively to assess the effect of H1 and of a combination of H1 and H2 antagonists on nasal symptoms, mediator release, and eosinophil count during an allergic reaction. NAC was performed at baseline (V1), 2 weeks after treatment with cetirizine 10 mg/day (V2), and after a combined therapy with cetirizine 10 mg and cimetidine 800 mg a day during the following week (V3). Results showed a significant (p < 0.05 or p < 0.01) relief of nasal symptoms such as: itching, sneezing, rhinorrhea and congestion, and of objective parameter such as: reduction of the number of sneezes after NAC at V2 and V3. Neither H1 antagonist nor a combination of H1 and H2 antagonists showed any effect on eosinophilia and ECP concentration caused by natural allergen exposure, nor on histamine and tryptase release immediately after NAC. When a combination of H1 and H2 antagonists was administered significant reduction of the nasal airway resistance and increase of the nasal air flow were demonstrated.

Assessment of early- and late-phase nasal obstruction in atopic patients after nasal allergen challenge

In order to study the types of nasal obstruction in allergic rhinitis, nasal allergen challenge was performed in 18 atopic patients, compared with a control group consisting of 10 healthy volunteers. Passive anterior rhinomanometry was used as an objective evaluation of nasal airway resistance. A 100% increase of nasal airway resistance was considered to be a positive reaction. In the control group, no obvious nasal obstruction was recorded after nasal phosphate buffered saline challenge. In the patient group, nasal obstruction occurred only after challenge in 94% during the early phase and in 82% during the late phase. During the late-phase four major types of nasal obstruction were found, i.e. no nasal obstruction; one-sided nasal obstruction only; bilateral nasal obstruction; and alternating nasal obstruction. Of the four types, the alternating type was the most common (47%) type, especially during the late-phase.

Monitoring nasal allergic inflammation by measuring the concentration of eosinophil cationic protein and eosinophils in nasal secretions

Quantitative measurement of the eosinophil cationic protein (ECP) concentration and the percentage of eosinophils in nasal secretions has greatly improved our understanding of the inflammatory process after natural allergen exposure. ECP and eosinophils were measured in the nasal secretions of 40 symptomatic patients with seasonal allergic rhinitis during the pollen season. Results showed a significant relationship between a high concentration of ECP (median: 410 ng/g, range: 6-2380 ng/g) and a high percentage of eosinophils (median: 13.5%, range: 1-85%). This quantitative study again demonstrated that infiltration by eosinophils and release of ECP play a key role in allergic rhinitis. It also suggests that the combined measurement of the percentage of eosinophils together with the ECP concentration in nasal secretions seems to be a very useful model in monitoring and assessing the condition of chronic nasal inflammation in patients with allergic rhinitis.

Nasal histamine challenge in nonallergic and allergic subjects evaluated by acoustic rhinometry

Nasal patency shows spontaneous variations but is influenced by a number of factors like exercise and allergic conditions. Nasal histamine challenge has been used to define nasal hypersensitivity. We have applied acoustic rhinometry as a new objective method to study the spontaneous variations of the nasal mucosa and its response to histamine challenge in 12 nonallergic subjects and 12 subjects with nasal allergy to pollen, but out of the pollen season. Measurements of the minimum cross-sectional area and the volume of the nasal cavities were done every 15 min for 6 h. More pronounced spontaneous variations, defined by the coefficient of variation of the measurements, were encountered in the allergic than in the nonallergic subjects, especially with regard to the minimum cross-sectional areas in the nasal cavities (P < 0.02). Allergic subjects showed increased sensitivity to histamine, as compared with nonallergic subjects, during low-concentration (0.1%) challenge (P < 0.05) and a prolonged effect of histamine challenge (P = 0.01). Antihistamine (cetirizine) had a significant effect on the histamine-induced symptoms and decrease of nasal dimensions during histamine challenge, but no significant effect on pollen-induced changes. In the allergic group, the decrease in minimum area during allergen provocation correlated with the level of specific IgE (r = 0.81; P = 0.0015).

Concentrations of chemical mediators in nasal secretions after nasal allergen challenges in atopic patients

By using a microsuction technique, a quantitative determination of chemical mediators in nasal secretions was performed in 18 hay-fever patients and in a control group of 10 healthy volunteers. The authors then compared these quantitative data for mediators with objective nasal findings counting the number of sneezes, passive anterior rhinomanometry (PAR) and nasal inspiratory peak flow. A sampling protocol was designed with a follow-up of 3 days after nasal allergen challenge (NAC) in order to investigate both early and late allergic reactions. Median baseline concentrations of five major mediators were obtained: histamine, 19 ng/g; leukotriene C4 (LTC4), 5.7 ng/g. tryptase, 0; prostaglandin D2 (PGD2), 477 pg/g; eosinophil cationic protein (ECP), 105 ng/g. Significant increases in histamine (214 ng/g), LTC4 (20 ng/g) and tryptase (28 microU/g) were found, but a significant decrease occurred in ECP (47 ng/g) and PGD (226 pg/g) immediately after NAC in the patients studied. Most ECP concentrations (94%) increased slowly 1 h after NAC and reached a significantly higher level 24 h later. In evaluating nasal symptoms, sneezes were present in a high percentage of cases (76%) during the early phase but were uncommon during the late phase (29%). Total nasal obstruction occurred in 94% during the early phase. In contrast, unilateral nasal obstruction presented in 82% during the late phase, whereas total nasal obstruction was present only in 41%. The most common type of late phase nasal obstruction shown by PAR was alternating nasal obstruction.

Concentrations of chemical mediators in nasal secretions of patients with hay fever during natural allergen exposure

By using the microsuction technique, quantitative determination of the chemical mediators in nasal secretions was performed in 40 patients with seasonal allergic rhinitis during the pollen season. The aim of this study was to investigate the actual concentrations of these important mediators in nasal secretions during natural allergen exposure so as to better understand the pathophysiology of allergic rhinitis. The median concentrations of four mediators, were histamine: 51.5 ng/g (range: 4-146 ng/g); tryptase: 0 (range: 0-84 microU/g); leukotriene C4 (LTC4): 23 ng/g (range: 11-77 ng/g); and eosinophil cationic protein (ECP): 410 ng/g (range: 6-2380 ng/g). The authors compared these concentrations with those of the same mediator found in a previous study of seasonal allergic rhinitis patients after nasal challenge outside the pollen season. The present study demonstrates that during the season allergic rhinitis reflects a chronic state of allergic inflammation of the nasal mucosa involving various inflammatory mediators induced by one or more episodes of early type allergic reaction.

Effect of experimental rhinovirus 39 infection on the nasal response to histamine and cold air challenges in allergic and nonallergic subjects

To determine whether a viral upper respiratory tract infection can alter the responsiveness of the nasal mucosa, paired intranasal histamine and cold air challenge sessions were performed before and after (8 to 13 days) experimental rhinovirus infection in 18 nonallergic subjects and 20 subjects with seasonal allergic rhinitis. The nasal response to the challenges was measured as symptom scores for rhinorrhea and congestion, counts for sneezing, weight for expelled secretions, and inspiratory conductance for nasal patency. For both sessions, a greater response was observed in allergic subjects for sneezing, symptoms of rhinorrhea and congestion, secretion weights provoked by histamine challenge, and secretion weights provoked by cold air challenge when compared with the nonallergic subjects. A comparison of the responses to the paired challenge sessions showed greater responses for sneezing, secretion weight and rhinorrhea to histamine and for secretion weight to cold air challenges performed after rhinovirus infection. No differences were observed between allergic and nonallergic subjects with respect to the degree of enhanced responsiveness secondary to viral infection. These results document an increased responsiveness of the nose to these stimuli during the postsymptomatic period of a rhinovirus infection in both allergic and nonallergic subjects.

Nonspecific nasal responsiveness in workers occupationally exposed to respiratory irritants

The aim of the study was to establish the level of the nonspecific nasal responsiveness in a group of workers (N = 84) occupationally exposed to respiratory irritants, and to compare it with its level in healthy subjects (N = 60). Another goal was to study the effect of occupational exposure to irritants, smoking, and atopy on nonspecific nasal responsiveness. The modified method of nonspecific nasal provocation with histamine developed by van Wijk and Dieges (Clin Allerg 17:563-570, 1987) was used. The method was performed by spraying doubling concentrations of histamine (0.03-32 mg/mL), starting with saline, in a cumulative manner into each nostril. The reaction was measured by total nasal resistance ("opening" interruption technique). The result of the test was expressed as provocation concentration of histamine that caused > or = 75% rise of total nasal resistance compared to its value measured after saline. We found a significantly higher percentage of nasal hyperreactors and a significantly greater nonspecific nasal responsiveness among 65 exposed workers (chi 2 = 78.6; p < 0.001, t = -5.48; p < 0.001, respectively) than in the group of healthy subjects. A significantly (t = 4.25; p < 0.001) increased nonspecific nasal responsiveness was observed during exposure when compared to nonspecific nasal responsiveness assessed after 2 weeks out of exposure, when tested in 19 patients. Higher smoking rate as measured by smoking category (number of cigarettes multiplied with years of smoking) was associated with the lower levels of nonspecific nasal responsiveness. Also, we failed to confirm a relation between atopy and nonspecific nasal responsiveness in a group of workers exposed to irritants.

Intranasal histamine challenge in normality and allergic rhinitis

A series of investigations was performed in which histamine challenge was used to compare nasal responsiveness in 20 normal subjects and 20 with allergic rhinitis. There was found to be a lower threshold of reactivity (D100) to histamine in allergic subjects as measured by resistance changes (geometric mean, 0.53 mg/ml; normal subjects, 2.15: p = 0.022). This may represent increased number or sensitivity of histamine receptors on the nasal capacitance vessels. The loss of a laser Doppler response to a supramaximal histamine stimulus (normal subjects, 102% increase in flux at 3 minutes; p < 0.05) was observed in patients with allergic rhinitis and indicates either a down-regulation of the capillary system or an altered effect of histamine on superficial vessels, perhaps mediated by a shift in histamine receptor type. There was an observed increase in neutrophils at the mucosal surface under baseline conditions (rhinitis median, 49.6%; normal subjects, 32.72%: p < 0.05), which suggests an important primary role in the pathogenesis of this condition for this active cell. The observed increase in secretory volume response to histamine in allergic subjects, which persisted beyond 40 minutes after a single D100 challenge, may be related to an altered sensitivity of glandular tissue. There are important changes in nasal reactivity to histamine challenge in allergic rhinitis that may have implications for its pathogenesis.

Rhinovirus 39 infection in allergic and nonallergic subjects

To determine if individuals with allergic rhinitis are hyperresponsive to upper respiratory tract viral infections, 20 allergic and 18 nonallergic, susceptible, adult volunteers were challenged and infected with rhinovirus type 39 before the pollen seasons. Before challenge and on each of 6 days of cloister, all volunteers were interviewed for symptoms and completed a test battery consisting of evaluations of secretion production by weighed tissues, nasal patency by active posterior rhinomanometry, nasal clearance by the dyed saccharin technique, pulmonary function by spirometry, eustachian tube function by sonotubometry, and middle ear status by tympanometry. The symptomatology and pathophysiology resulting from the rhinovirus infection were consistent with those reported in previous studies with this challenge system. Between-group comparisons revealed no differences in symptom presentation, nasal secretion production, or overall pathophysiologic response. However, for decreased mucociliary clearance rate, increased nasal congestion, eustachian tube dysfunction, and symptoms of sneezing, the allergic group demonstrated an earlier onset compared with that of the nonallergic group. The biologic significance of the differences in onset of dysfunction is tempered by the observation that the temporal pattern of responses in the allergic group was similar with that of nonallergic subjects in previous studies. The results of the present study do not support the hypothesis of a physiologic hyperresponsiveness to rhinovirus type 39 infection in allergic subjects during nonallergy seasons.

Nasal hyper-responsiveness to histamine, methacholine and phentolamine in patients with perennial non-allergic rhinitis and in patients with infectious rhinitis

Recently it has been shown that patients with atopic rhinitis and with an allergy to house dust mites have a stronger nasal response to insufflation of histamine, methacholine and phentolamine than a control group. This hyper-responsiveness could not be demonstrated in patients with perennial non-allergic rhinitis, unless the patients were selected according to the predominant symptoms in the history. Patients with rhinorrhoea ('runners') proved to be hyper-responsive to methacholine compared with normal controls. The existence of two subpopulations was emphasized by hyper-responsiveness to both histamine and methacholine in the runners group compared with the patients with a stuffy nose ('blockers'). Patients with chronic nasal infections (characterized by recurrent episodes of purulent discharge) showed no hyper-responsiveness at all, indicating that either hyper-reactivity does not play an important part in this patient population or methods to detect hyper-reactivity in this group are inadequate. In contrast to our earlier observations in patients with atopic rhinitis, increased responsiveness to phentolamine could not be detected either in the patients with perennial rhinitis or in the patients with infectious rhinitis, indicating that the possible alpha-adrenergic dysfunction found in patients with atopic rhinitis is restricted to this group.

Physiologic responses to intranasal dose-response challenges with histamine, methacholine, bradykinin, and prostaglandin in adult volunteers with and without nasal allergy

The dose-response (dose, 0.01, 0.05, 0.1, 0.5, 1, and 5 mg) profiles of 10 atopic and 10 nonatopic subjects were determined for nasal patency, secretion weight, pulmonary function, eustachian tube function, middle-ear function, and symptoms after intranasal inhalation challenges with histamine, bradykinin, methacholine, prostaglandin D2, and prostaglandin F2 alpha (PGF2 alpha). Results demonstrated that challenge with PGF2 alpha increased nasal patency, whereas challenge with all other substances decreased patency. The relationship between substances in eliciting a nasal congestive response was prostaglandin D2 greater than histamine greater than bradykinin greater than methacholine. A similar effect ordering was noted for the postchallenge development of eustachian tube dysfunction. Secretion weights were significantly greater after challenge with histamine compared to all other substances. A decrease in pulmonary function was observed only after challenge with PGF2 alpha, although the effect was not statistically significant. No changes in middle-ear pressure were observed for challenges with any of the substances. Only histamine challenge provoked sneezing, whereas challenge with either of the prostaglandins provoked cough. With the exception of methacholine, all substances caused symptoms of rhinorrhea, congestion, and sore throat. Bradykinin was particularly effective in provoking "pain/pressure"-related symptoms. With the exception of secretion weight, the differences between responses of atopic and nonatopic subjects were not statistically significant. These results document mediator specificity in the physiologic and symptomatic responses to intranasal challenge.

Nasal provocation with histamine in allergic rhinitis patients: clinical significance and reproducibility

In a selected group of rhinitis patients (n = 12) with an IgE-mediated allergy to house dust mites, the nasal response to insufflation of histamine chloride appeared to be related to symptom scores obtained from the patients. In contrast to the sum of the nasal airway resistances (NAR) induced by all doses of histamine, the total amount of secretion and total number of sneezes could be predicted from clinical scores. The reproducibility of the nasal provocation test was tested by comparison of the test results in two sessions with a 1-week interval. The correlation between both sessions was highest with respect to nasal secretion (r = 0.87; P less than 0.001) and the number of sneezes (r = 0.76; P = 0.004). The correlation coefficient was 0.71 (P = 0.01) when the nasal airway resistance was used in the assessment of nasal response. A good reproducibility of the nasal provocation test was also obtained using an end-point titration method and determining the concentration required to produce 0.5 ml secretion and/or five sneezes as the end-point (r = 0.76; P = 0.004). The concentration required to double nasal airway resistance yielded a correlation coefficient of 0.56 (P = 0.052). We conclude that the clinical significance of nasal provocation with histamine increases when, besides nasal airway resistance, the amount of secretion and the number of sneezes is used in the assessment of the nasal response.(ABSTRACT TRUNCATED AT 250 WORDS)

Nasal allergy to avian antigens

This study describes the case of a patient who developed symptoms of rhinoconjunctivitis on exposure to budgerigars and parrots. An IgE-mediated allergy to budgerigar, parrot and pigeon antigens was demonstrated using both in-vivo challenge tests (skin and nasal provocation tests) and in-vitro investigations (radio-allergo-sorbent test, histamine release test). The study shows that the development of nasal disease can be associated with allergy to avian antigens.