Airway function and nasal inflammation in seasonal allergic rhinitis and asthma

Biomarkers in allergen immunotherapy: Focus on eosinophilic inflammation

Asthma and allergic rhinitis (AR) are 2 of the most common chronic inflammatory disorders and they appear to be on the rise. Current pharmacotherapy effectively controls symptoms but does not alter the underlying pathophysiology. Allergen immunotherapy (AIT) is an evidence-based therapy for asthma and AR and has been recognized as the only therapeutic method that actually modifies the allergic disease process. There is a lack of objective markers that accurately and reliably reflect the therapeutic benefits of AIT. A biomarker indicating patients that would benefit most from AIT would be invaluable. Eosinophilic inflammation is a cardinal feature of many allergic diseases. Biomarkers that accurately reflect this inflammation are needed to better diagnose, treat, and monitor patients with allergic disorders. This review examines the current literature regarding AIT's effects on eosinophilic inflammation and biomarkers that may be used to determine the extent of these effects.

Allergic Rhinitis

Allergic rhinitis (AR) affects more than 400 million people worldwide, making it 1 of the most prevalent chronic diseases. Childhood AR is increasing, and almost half of patients with AR develop symptoms before age 6 years. Although a diagnosis of AR is associated with higher socioeconomic status, underserved and urban populations have more indoor aeroallergen sensitizations and are likely underdiagnosed with AR, further exacerbating health-care disparities. AR negatively impacts quality of life, school performance, and overall health outcomes. Untreated AR in children increases the risk for poor asthma control, increased asthma severity, and exacerbations. Many patients believe that they have seasonal allergies only but in reality have both perennial and seasonal AR, which may change the approach to allergen avoidance measures and treatment recommendations. Pharmacotherapy of AR has expanded, with many intranasal corticosteroids, intranasal antihistamines, and second-generation oral antihistamines approved for pediatric use. Allergen immunotherapy, including both subcutaneous and sublingual forms, are approved for children and are disease modifying, potentially reducing further allergen sensitization and progression to asthma. Many of the currently available biological therapies indicated for pediatric asthma and/or atopic diseases reduce AR symptoms as well. Children with moderate to severe or refractory AR or those with comorbidities should be referred to allergists for diagnostic testing and expanded management options, including immunotherapy and potential biological treatment.

Efficacy of subcutaneous immunotherapy for patients with asthma and allergic rhinitis in Korea: effect on eosinophilic inflammation

Background

Atopic asthma (AA) and allergic rhinitis (AR) are often seen as comorbidities and specific immunotherapy (SIT) is considered evidence-based treatment for them both.

Objective

The purpose of this study was to evaluate the efficacy of multiallergen subcutaneous SIT (SCIT) in reducing nasal and sputum eosinophilia, symptom scores, and impaired lung function in Korean pediatric patients with AR and AA.

Methods

Children aged 6-15 years with a documented history of bronchial asthma and seasonal/perennial AR were recruited then randomly selected to 1 of 2 groups: "immunotherapy group" (inhaled corticosteroids [ICS] and short-acting beta₂-agonist [SABA] + subcutaneous injection of standardized extracts of up to 4 allergens [n = 53]) or "drug only group" (ICS and SABA only [n = 19]). All data were collected retrospectively.

Results

Comparing the 2 treatment groups, the immunotherapy group showed a significantly (p = 0.006) greater reduction in nasal eosinophilia over the 3-year treatment period. Only the immunotherapy group exhibited a significant reduction in sputum eosinophilia over the 3-year treatment period (p = 0.003). Fifty-one point one percent of patients in the immunotherapy group showed significant improvement in the methacholine challenge test negative conversion rate compared to only 17.65% in the drug only group (p = 0.0168). There were significantly greater improvements in symptom scores in the immunotherapy group compared to the drug only group. For all allergens tested, only house dust mite reactivity changed significantly over the treatment period and only in the immunotherapy group (Dermatophagoides pteronyssinus [p < 0.0001] and Dermatophagoides farina [p = 0.035]).

Conclusion

SCIT was associated with greater improvements in lung function and bronchial hyperresponsiveness and reductions in nasal and sputum eosinophilia and allergen reactivity. Changes in symptom scores were also much greater in patients receiving SCIT when compared to those who did not receive it. Korean children with AA and AR respond well to long-term multiallergen SCIT.

Determinants of severe exercise-induced bronchoconstriction in Nigerian children with asthma

BACKGROUND/PURPOSE

Asthmatics with severe exercise-induced bronchoconstriction (EIB) are at high risk of exacerbations. The purpose of this study was to determine the prevalence, phenotypic, and laboratory determinants of severe EIB in Nigerian children with asthma.

METHODS

Children with controlled asthma (n = 101) underwent characterization and free-running exercise bronchoprovocation at a center in Nigeria. Lung function was measured before, then 5, 10, 15, and 30 minutes after 6 to 8 minutes exercise. Severe EIB was defined as ≥50% decrease in forced expired volume in 1 second (FEV₁ ) from preexercise. Serum vitamin D and total antioxidant capacity were measured chromatographically. Factors predicting severe EIB were tested by logistic regression.

RESULT

The sample was enriched in children with corticosteroid-naïve, mild intermittent asthma (71%). Thirteen percent had no EIB, 22% had severe and 65% nonsevere EIB. Children with severe EIB had higher preexercise FVC (105% vs 96%; P = .03) and FEV₁ (98% vs 90%; P = .07), greater obesity (13.6% vs 1.3%; P = .02), more allergic rhinitis (AR) (63.6% vs 35.4%; P = .03), but less exposure to household pets (31.8% vs 72.2%; P = .003) compared to children with nonsevere EIB. Significant determinants (odds ratios/confidence intervals) for severe EIB were obesity = 12.3 (1.2-125.1), AR = 3.18 (1.19-8.52), blood eosinophilia = 1.005 (1.001-1.009), and hypovitaminosis D = 0.87 (0.81-0.93).

CONCLUSION

In Nigerian children with asthma, severe EIB is common and associated with remediable comorbidities including type 2 pattern inflammation and vitamin D deficiency.

Severe Asthma and Allergy: A Pediatric Perspective

Severe asthma in children is associated with significant morbidity and lung function decline. It represents a highly heterogeneous disorder with multiple clinical phenotypes. As its management is demanding, the social and economic burden are impressive. Several co-morbidities may contribute to worsen asthma control and complicate diagnostic and therapeutic management of severe asthmatic patients. Allergen sensitization and/or allergy symptoms may predict asthma onset and severity. A better framing of "allergen sensitization" and understanding of mechanisms underlying progression of atopic march could improve the management and the long-term outcomes of pediatric severe asthma. This review focuses on the current knowledge about interactions between severe asthma and allergies.

SLIT's Prevention of the Allergic March

PURPOSE OF REVIEW

The progression of atopic disorders from atopic dermatitis in infants to allergic rhinitis and asthma in children, adolescents, and adults defines the allergy march. Allergen immunotherapy is the only causal treatment altering the immunological mechanism underlying the allergic diseases. The sublingual administration route is more acceptable than the subcutaneous one in pediatric age.

RECENT FINDINGS

Several studies show the efficacy and safety profile of sublingual immunotherapy (SLIT) for the treatment of respiratory allergy diseases, but few data are available on its effect of primary and secondary prevention of allergic disease. The purpose of this manuscript is to review the latest studies addressing the effect of SLIT on the development of new sensitizations in not sensitized or already sensitized patients and progression of the allergy march.

Clinical Effect of Endoscopic Vidian Neurectomy on Bronchial Asthma Outcomes in Patients with Coexisting Refractory Allergic Rhinitis and Asthma

Background The prevalence of both allergic rhinitis and bronchial asthma is high throughout the world; their mutual influence on each other has been documented in many studies. However, studies regarding surgical intervention are limited. Objective To evaluate the clinical significance of endoscopic vidian neurectomy on bronchial asthma outcomes in patients with coexisting refractory allergic rhinitis and asthma. Methods A total of 109 patients with moderate to severe persistent intractable allergic rhinitis and mild/moderate asthma were allocated to the bilateral endoscopic vidian neurectomy group (group 1) or conservative medication group (group 2) according to the patients' self-selection. The Rhinoconjunctivitis Quality of Life Questionnaire, Visual Analog Scale, Asthma Quality of Life Questionnaire, Total Asthma Symptom Score, and medication scores were evaluated at six months, one year, and three years after undergoing the initial treatments. Multivariate analysis was performed to determine which triggers of asthma attacks were associated with improved asthma outcomes in patients. Results Ninety-five patients were followed up for at least three years. Postoperative scores of Rhinoconjunctivitis Quality of Life Questionnaire and Visual Analog Scale were significantly lower than preoperative scores during follow-up in group 1 and were significantly lower than those of group 2. Postoperative scores of Asthma Quality of Life Questionnaire at the three follow-up time points were higher than the preoperative scores in group 1. The Total Asthma Symptom Score was not significantly decreased in group 1. The medication scores for allergic rhinitis and asthma were gradually reduced after surgery. At the end of the follow-up, the improvement rates for allergic rhinitis and asthma were 90.6% and 45.3%, respectively. Asthma outcomes were significantly improved by controlling rhinitis symptoms in patients whose asthma attacks were induced by "rhinitis onset" or "weather change." Conclusion Controlling allergic rhinitis symptoms by bilateral endoscopic vidian neurectomy can significantly improve asthma outcomes in patients whose asthma attacks are induced by rhinitis onset and/or cold air.

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.

Risk factors for asthma occurrence in children with early-onset atopic dermatitis: An 8-year follow-up study

BACKGROUND

Children with early-onset atopic dermatitis (AD) are at substantial risk of developing asthma later in life, and identifying the critical window of detrimental exposure is advantageous for implementing preventive actions. The aim of this study was to evaluate the role of exposure to environmental modifiers during pregnancy and early childhood in asthma occurrence in an infantile AD cohort.

METHODS

Eligible study participants were selected from the Taiwan Birth Cohort Study, which enrolled 24 200 newborns in 2005. We enrolled those cases who had been diagnosed as having AD before 3 years of age and followed them up till age 8. We excluded those ever diagnosed with asthma before AD onset. The dependent variable was defined in terms of whether the participant was diagnosed as having asthma before 8 years of age. We applied logistic regression models to evaluate the risks of exposure to different determinants in asthma occurrence.

RESULTS

A total of 1549 children with AD had completed the 8-year follow-up, and 334 (21.6%) of them had asthma. The results revealed that male sex, lower birth order, maternal asthma history, maternal obesity before pregnancy, and environmental tobacco smoke exposure before 3 years of age were significant risk factors for further development of asthma. Furthermore, food allergy during early life, lower respiratory tract infection, and longer durations of symptomatic AD influenced asthma development later in life.

CONCLUSIONS

The findings confirmed the critical determinants for asthma occurrence in infantile AD, which may enable a more personalized approach to the prevention of asthma.

Exercise-Induced Bronchospasm and Allergy

Sport is an essential part of childhood, with precious and acknowledged positive health effects but the impact of exercise-induced bronchoconstriction (EIB) significantly reduces participation in physical activity. It is important to recognize EIB, differentiating EIB with or without asthma if the transient narrowing of the airways after exercise is associated with asthmatic symptoms or not, in the way to select the most appropriate treatment among the many treatment options available today. Therapy is prescribed based on symptoms severity but diagnosis of EIB is established by changes in lung function provoked by exercise evaluating by direct and indirect tests. Sometimes, in younger children it is difficult to obtain the registration of difference between the preexercise forced expiratory volume in the first second (FEV1) value and the lowest FEV1 value recorded within 30 min after exercise, defined as the gold standard, but interrupter resistance, in association with spirometry, has been showed to be a valid alternative in preschool age. Atopy is the main risk factor, as demonstrated by epidemiologic data showing that among the estimated pediatric population with EIB up to 40% of them have allergic rhinitis and 30% of these patients may develop adult asthma, according with atopic march. Adopting the right treatment and prevention, selecting sports with no marked hyperventilation and excessive cooling of the airways, children with EIB can be able to take part in physical activity like all others.

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.

Vitamin D and the development of allergic disease: how important is it?

Vitamin D has known effects on lung development and the immune system that may be important in the development, severity, and course of allergic diseases (asthma, eczema, and food allergy). Vitamin D deficiency is prevalent worldwide and may partly explain the increases in asthma and allergic diseases that have occurred over the last 50-60 years. In this review, we explore past and current knowledge on the effect of vitamin D on lung development and immunomodulation and present the evidence of its role in allergic conditions. While there is growing observational and experimental evidence for the role of vitamin D, well-designed and well-powered clinical trials are needed to determine whether supplementation of vitamin D should be recommended in these disorders.

Association of nasal inflammation and lower airway responsiveness in schoolchildren based on an epidemiological survey

BACKGROUND/AIMS

We sought to increase our understanding of the rhinitis-asthma relationship and improve strategies for the treatment of patients with these diseases. The aim of this study was to identify a connection between upper airway inflammation and lower airway responsiveness.

METHODS

We counted eosinophils on nasal smears, and performed spirometry, allergic skin tests, and methacholine challenge tests in 308 schoolchildren plus a questionnaire on respiratory symptoms. The methacholine concentration causing a 20% fall in forced expiratory volume in 1 second (PC20 < 25 mg/mL) was used as the threshold of bronchial hyperresponsiveness (BHR).

RESULTS

In total, 26% of subjects had positive nasal eosinophils on a smear, and 46.2% of subjects had BHR at < 25 mg/mL methacholine PC20. Nasal symptoms were higher in subjects with than without nasal eosinophils (p = 0.012). Asthma symptoms did not differ between subjects with and without nasal eosinophils. Nasal eosinophils were higher in subjects with atopy than those without (p = 0.006), and there was no difference in PC20 methacholine according to atopy (15.5 ± 1.07 vs. 17.5 ± 0.62; p > 0.05). No difference in BHR was detected when comparing subjects with and without nasal eosinophils. There were significant differences in the PC20 between subjects with greater than 50% nasal eosinophils and without nasal eosinophils (11.01 ± 2.92 mg/mL vs. 17.38 ± 0.61 mg/mL; p < 0.001).

CONCLUSIONS

These findings demonstrated that nasal eosinophilic inflammation might contribute to lower airway responsiveness in schoolchildren, based on an epidemiological survey.

Subjective and objective assessments of seasonal effect in children with seasonal allergic rhinitis

BACKGROUND

Epidemiological and clinical studies suggest a relationship between rhinitis and asthma. Upper and lower airways may be influenced by a common inflammatory process.

OBJECTIVE

This study aimed to investigate the relationships between rhinitis symptom scores, and both nasal and bronchial airflow among children with seasonal allergic rhinitis (SAR) by means of spirometric and rhinomanometric measurement during and outside the pollen season.

METHODS

Twenty-nine children with both seasonal allergic rhinitis and asthma (AR+A), 30 children with SAR and no asthma (AR) and 36 non-allergic healthy children were evaluated prospectively during and outside the pollen season. Symptom severity was evaluated using both total symptom score and visual analog score (VAS). All participants also received rhinomanometric evaluation and pulmonary function testing.

RESULTS

In children with SAR the median total nasal flow, FEV1, FEF25-75 values were lower than control group during pollen season (p=0.01, p<0.001 and p<0.001 respectively). They had also higher total nasal resistance compared with control groups (p=0.01). Nasal symptom scores were higher among patients with concurrent asthma than patients who had only SAR out of pollen season (p<0.001). There was no significant difference between SAR participants with or without asthma and control group in terms of total nasal flow and total nasal resistance measured out of season (p=0.105 and p=0.19). FEF25-75 values of patients with and without asthma were significantly lower than those of controls out of season (p=0.022, p<0.001 respectively).

CONCLUSION

Our data suggests that as the presence of AR worsens asthma control, the presence of asthma may worsen symptoms of AR out of pollen season. We found that total nasal flow, FEV1, FEF25-75 values of patients with SAR were lower than those of controls out of season. FEF25-75 values of patients with asthma and without asthma were significantly lower than those of controls out of season. Thus, a careful evaluation of lower airways should be performed in even patients with seasonal allergic rhinitis alone.

Nasal expiratory sound analysis for evaluation of nasal patency in perennial allergic rhinitis patients treated with nasal corticosteroids

PURPOSE

To assess the efficacy of nasal expiratory sound analysis in determining the degree of nasal obstruction.

MATERIALS AND METHODS

We have analyzed and recorded the expiratory nasal sounds in 18 healthy controls and in 30 patients with inferior turbinate hypertrophy before and after the administration of nasal corticosteroid treatment. Analysis consisted of the time-expanded waveform, spectral analysis with time-averaged fast Fourier transform and waveform analysis of nasal sound.

RESULTS

Before treatment, an increase in sound intensity at high frequency was observed in the sound analyses of the patients, whereas after treatment, a decrease in sound intensity at high frequency was noted in the sound analyses of the patients. The differences between the patients and the control group were statistically significant. Data obtained with the Odiosoft-Rhino method were correlated with symptom scores and endoscopic examination.

CONCLUSION

Expiratory nasal sound is a practical and objective tool, which can be reliably used not only for the assessment of the degree of nasal blockage but also for the comparison of different treatment alternatives.

Sinusitis, Rhinitis, Asthma, and the Single Airway Hypothesis

The one airway, one disease hypothesis proposes that the upper and lower airways share the same physiology and histomorphology. Epidemiological clinical studies support a link between rhinosinusitis and asthma. The relationship can occur in both directions, with nasal allergen challenge leading to inflammatory changes in the lower airway and bronchoprovocation studies of the lower airway leading to inflammatory changes in the upper airway. In addition, both similarities and differences exist in the pathogenesis of nasal polyps and asthma. The mechanism for the connection between the upper and lower airways is a matter of great debate. It has been proposed that inflammatory changes in the lower airway may lead to systemic inflammatory effects that play a role in increased bronchial hyperresponsiveness. Similarly, lower airway inflammatory changes may affect nasal airway patency via systemic effects. Moreover, nasopharyngeal-bronchial reflexes may play a non-immunologic role in the interaction between the lower and upper airways. An example of the connection between the upper and lower airways is found in aspirin-exacerbated respiratory disease whereby leukotrienes play a role in the pathology of chronic rhinosinusitis with polyps and asthma. It is also been observed that the treatment of asthma is hindered by untreated rhinosinusitis.

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.

The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma

The development of atopic dermatitis (AD) in infancy and subsequent allergic rhinitis and asthma in later childhood is known as the atopic march. This progressive atopy is dependent on various underlying factors such as the presence of filaggrin mutations as well as the time of onset and severity of AD. Clinical manifestations vary among individuals. Previously it was thought that atopic disorders may be unrelated with sequential development. Recent studies support the idea of a causal link between AD and later onset atopic disorders. These studies suggest that a dysfunctional skin barrier serves as a site for allergic sensitization to antigens and colonization of bacterial super antigens. This induces systemic Th2 immunity that predisposes patients to allergic nasal responses and promotes airway hyper reactivity. While AD often starts early in life and is a chronic condition, new research signifies that there may be an optimal window of time in which targeting the skin barrier with therapeutic interventions may prevent subsequent atopic disorders. In this review we highlight recent studies describing factors important in the development of atopic disorders and new insights in our understanding of the pathogenesis of the atopic march.

Gene-Gene Interaction Between CCR3 and Eotaxin Genes: The Relationship With Blood Eosinophilia in Asthma

Purpose

Eosinophils function as an effector cell in the development of asthma and allergic disease. Eotaxins are cytokines that promote pulmonary eosinophilia via the receptor CCR3. Single-nucleotide polymorphisms (SNPs) in CCR3 and eotaxin genes are associated with asthma. In this study, genetic interactions among SNPs of several eotaxin genes and CCR3 were assessed and their relationship with blood eosinophilia in asthma was examined.

Methods

A total of 533 asthmatics were enrolled in this study. Asthmatics with eosinophilia (>0.5×10⁹/L) were compared with those without eosinophilia (≤0.5×10⁹/L). Chi-square tests were used to compare SNP frequencies. Two different models were used to evaluate gene-gene interactions: logistic regression and generalized multifactor dimensionality reduction (GMDR).

Results

EOT2+304C>A (29L>I) was significantly associated with 3 of the 4 CCR3 SNPs among asthmatics with eosinophilia (P=0.037-0.009). EOT2+304C>A (29L>I) and the CCR3 SNPs were also significantly associated with blood eosinophilia in an interaction model constructed by logistic regression (P=0.0087). GMDR analysis showed that the combination of EOT2+304C>A (29L>I) and CCR3-174C>T was the best model (accuracy=0.536, P=0.005, CVC 9/10).

Conclusions

The epistatic influence of CCR3 on eotaxin gene variants indicates that these variants may be candidate markers for eosinophilia in asthma.

A case of eosinophilic fasciitis presenting as pitting edema of the lower extremities

Eosinophilic fasciitis is a rare disease characterized by diffuse fasciitis with peripheral eosinophilia and progressive induration and thickening of the skin and soft tissues. We report a 19-year-old female who presented with pitting edema in both lower extremities. She had a history of excessive physical activity before her symptoms developed. Physical examination revealed 2+ pitting edema in both lower legs. She complained of mild pain in both knee joints and feet, with no tenderness or heating sensations. Laboratory results were unremarkable except for severe eosinophilia. Parasite infection, venous thrombosis, and cardiac and renal problems were excluded. A magnetic resonance imaging study of both lower extremities revealed increased signal intensity in the subcutaneous lesions, consistent with superficial inflammation of the fascia. Mixed perivenular lymphoplasmacytic and eosinophilic infiltration in the subcutaneous lesion were observed on biopsy. The patient was treated with corticosteroids, resulting in remarkable improvement in both edema and eosinophilia.

Comparison of leukotriene receptor antagonists and anti-histamines as an add-on therapy in patients with asthma complicated by allergic rhinitis

Patients with asthma are often complicated by allergic rhinitis, and the intimate pathophysiological association between allergic rhinitis and asthma often imposes a significant morbidity on affected individuals. The present study was conducted to assess the clinical efficacies of leukotriene receptor antagonists (LTRAs) and anti-histamines on asthma as an add-on therapy in patients with asthma complicated by allergic rhinitis. Consecutive patients with asthma were recruited to fill in systematic self-administered questionnaires concerning symptoms and conditions related to asthma and allergic rhinitis. The questionnaire was conducted twice, one month apart, and the attending physicians gave detailed information on disease control and medications on both occasions. In the study 3,140 patients with asthma participated, and 634 had concomitant allergic rhinitis (mean age: 53.1, 389 female). The second survey disclosed that treatment with LTRAs or anti-histamines had been added in 26 patients and 19 patients, respectively, without any changes in other medications. There were no significant differences in age, gender, severity of disease, or baseline treatments. The initial survey indicated that the patients who were treated with LTRAs had significantly more severe asthma-related symptoms (i.e. wheeze, cough and sleep disturbance) and experienced greater dissatisfaction with the treatment than did those who were treated with anti-histamines. The second survey disclosed significant reductions in sneezing (p=0.03), rhinorrhea (p=0.01), dyspnea (p=0.046), sleep disturbance (p=0.02), over-all asthma symptoms (p=0.013), and an improvement in satisfaction with treatment (p=0.019) in patients to whom LTRAs were added-on, whereas the patients receiving anti-histamines reported no significant changes in these symptoms. These results suggest that LTRAs are more effective than anti-histamines as an add-on therapy in symptomatic patients with asthma complicated by allergic rhinitis.

Nasal eosinophilia can predict bronchial hyperresponsiveness in persistent rhinitis: evidence for united airways disease concept

BACKGROUND

Nasal eosinophils may be indicative of bronchial hyperresponsiveness (BHR) in rhinitis concerning the "united airways disease" theory. This study was designed to evaluate the relationship between nasal eosinophilia and BHR in persistent perennial rhinitis patients.

METHODS

Thirty-seven patients (12 males and 25 females, mean age: 33.3 ± 10.4 years) were included in the study. Skin-prick test, nasal symptom score, nasal smears, methacholine bronchial challenge test, and nasal rhinometry were obtained in all patients. Eosinophil count in nasal smears was expressed as a percentage of the total cells. None of the patients had asthma.

RESULTS

There was no difference between the number of atopic and nonatopic patients having BHR (4/20 versus 4/17; chi-squared = 0.07; p > 0.05). Total nasal flow was lower and percentage of nasal eosinophils was higher in the patients with BHR than in patients without BHR (p = 0.012 and p = 0.009, respectively). A cutoff point of 68% nasal eosinophils yielded a sensitivity of 100% (63.1-100) and a specificity of 58.6% (38.9-76.5) to determine the presence of BHR. Positive likelihood ratio for the value of eosinophils above cutoff value was 2.42 (1.8-3.3).

CONCLUSION

This study shows the relationship between nasal eosinophils and BHR in persistent perennial rhinitis patients. Nasal eosinophil percentage below cutoff value indicates that a patient does not have BHR.

Anti-allergic effects of total bakkenolides from Petasites tricholobus in ovalbumin-sensitized rats

The anti-allergic effect of total bakkenolides from the rhizome of Petasites tricholobus (BAPT) was evaluated in an ovalbumin-induced allergic rhinitis model in male Wistar rats. The major components of the bakkenolide fraction are bakkenolide-D, bakkenolide-B, bakkenolide-IIIa and bakkenolide-IVa, which account for 60.04% of the total. The rats were treated with 40 mg/kg, 20 mg/kg, 10 mg/kg or 5 mg/kg BAPT, and 0.942 mg/kg loratadine and 0.5% gum tragacanth were used as positive and negative controls, respectively. The frequency of nose rubbing and sneezing was observed, the number of eosinophils infiltrating into the nasal tissue was counted, and serum levels of IL-4 and histamine were determined by ELISA. The results showed that BAPT had a beneficial effect on allergic rhinitis in ovalbumin-sensitized Wistar rats, which was evidenced by a significant decrease in the frequency of sneezing, the number of eosinophils infiltrating into the nasal tissue, and the serum levels of IL-4 and histamine. BAPT may therefore be a potential antiallergic drug.

The atopic march: progression from atopic dermatitis to allergic rhinitis and asthma

Atopic dermatitis (AD) is an inflammatory disease characterized by pruritic skin lesions. The pathogenesis of AD may include disrupted epidermal barrier function, immunodysregulation, and IgE-mediated sensitization to food and environmental allergens. AD is also part of a process called the atopic march, a progression from AD to allergic rhinitis and asthma. This has been supported by multiple cross-sectional and longitudinal studies and experimental data. Research on the mechanisms of AD has been centered on the adaptive immune system with an emphasis on the T-helper 1 (Th1)-Th2 paradigm. Recently, the conceptual focus has largely shifted to include a primary defect in the epithelial barrier as an initial event in AD providing a significant insight into the disease initiation and pointing to a complex secondary interplay of environmental and immunological sequelae with barrier disruption. Further understanding of AD will help the development of more effective treatment for AD and ultimately, preventative algorithms for the atopic march. In this review we highlight recent advances in our understanding of the pathogenesis of AD and the atopic march.

The patient with allergies

Allergic disease affects a sizeable percentage of the general population, has a significant impact on patient quality of life, and exerts a significant financial burden on society. Atopic symptoms from inhalant allergens are among the most frequent complaints in outpatient medical visits. Key history and physical examination findings help to distinguish allergic rhinitis from other forms of chronic rhinosinusitis. Diagnostic testing may not be necessary unless immunotherapy is contemplated.

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.

Sinonasal pathology in nonallergic asthma and COPD: 'united airway disease' beyond the scope of allergy

BACKGROUND

In contrast to the epidemiological and clinical association between allergic rhinitis and asthma, upper airway inflammation is less characterized in patients with nonatopic asthma and virtually unexplored in chronic obstructive pulmonary disease (COPD). Here, sinonasal pathology is studied in patients with allergic asthma, nonallergic asthma and COPD.

METHODS

Ninety patients with stable bronchial disease were included in the study, of which 35 were diagnosed with allergic asthma, 24 with nonallergic asthma and 31 with COPD. Concurrently, 61 control subjects without pulmonary disease were included and matched for age and smoking habits respectively with the asthma and the COPD group. Sinonasal symptoms were evaluated on a visual analogue scale and rhinosinusitis-related impairment of quality of life was assessed with the sino-nasal outcome test-22 (SNOT-22) questionnaire. Nasal mucosal abnormalities were quantified with nasal endoscopy and nasal secretions collected for measuring inflammatory mediators.

RESULTS

Allergic asthmatics, nonallergic asthmatics and COPD patients reported more nasal symptoms than their respective control subjects, had a higher SNOT-22 score and presented more mucosal abnormalities in the nose. Nasal secretions of both allergic and nonallergic asthmatics contained higher levels of eotaxin, G-CSF, IFN-gamma and MCP-1 than controls. Allergic asthmatics had higher nasal IP-10 levels as well. COPD-patients had higher nasal levels of eotaxin, G-CSF and IFN-gamma than controls.

CONCLUSION

Patients with allergic and nonallergic asthma and COPD show increased nasal symptoms and more nasal inflammation. Hence, our data confirm the 'united airways' concept to be beyond the scope of allergic asthma.

Genetic effect of CCR3 and IL5RA gene polymorphisms on eosinophilia in asthmatic patients

BACKGROUND

Eosinophilic infiltration and peripheral blood eosinophilia in asthma require the cooperation of eosinophil-specific cytokines and chemokines and their receptors.

OBJECTIVE

We investigated the association of polymorphisms in CCR3 and IL5RA with asthma susceptibility or peripheral blood eosinophilia and the effects of the polymorphisms on receptor expression.

METHODS

Polymorphisms in CCR3 and IL5RA were identified and genotyped in 576 asthmatic patients and 180 healthy control subjects. CCR3 and IL-5 receptor alpha (IL-5R alpha) protein expression on eosinophils was measured by means of flow cytometry.

RESULTS

Although polymorphisms in CCR3 were not associated with asthma susceptibility, the CCR3 haplotype ht2 showed a negative gene dose effect on the eosinophil count (P = .003-.009). IL5RA c.-5091G>A was weakly associated with eosinophil count. The effects of ht2 were greater when paired with IL5RA c.-5091A (P = .001-.002). CCR3 protein expression was higher on eosinophils of asthmatic patients without ht2 than in those with ht2. Asthmatic patients with the IL5RA c.-5091A allele showed higher IL-5R alpha expression than those who were homozygous for the G allele.

CONCLUSION

The genetic association between CCR3 polymorphisms and the number of circulating eosinophils was revealed as a novel finding. These associations were more pronounced when the CCR3 polymorphisms were paired with polymorphisms in IL5RA. The protein expression levels of CCR3 and IL-5R alpha on peripheral blood eosinophils are associated with the polymorphisms on their own genes.

CLINICAL IMPLICATIONS

The identification of single nucleotide polymorphisms and haplotypes of CCR3 and IL5RA might be useful in developing markers for intermediate phenotypes of eosinophil number and in designing strategies to control diseases related to hypereosinophilia.

Nasobronchial interaction mechanisms in allergic airways disease

PURPOSE OF REVIEW

During the past few decades, the incidence of sensitization to inhaled allergens as well as allergic airways disease has grown steadily. Genetic and environmental factors are recognized as etiologic factors in the development of allergic airway disease, with allergic rhinitis often preceding the development of asthma. Allergic rhinitis is considered a risk factor for the development of asthma, and almost all allergic asthmatic patients have rhinitis. Insight into the risk factors responsible for allergic airways disease and the interaction between the involved organs results in a better diagnostic and therapeutic approach in global airway allergy syndrome.

RECENT FINDINGS

Recent studies have shown that local tissue factors, such as microbial stimuli and systemic inflammatory mechanisms, play a role in the clinical expression of the allergic airway syndrome. In addition, impaired nasal function affects the lower airways of asthmatic patients via different pathways. To date, most human and animal data point towards a systemic pathway linking the upper and lower airways, involving both bloodstream and bone marrow. Recent clinical trials and current guidelines underline the importance of an integrated treatment strategy involving both ends of the respiratory tract.

SUMMARY

This review provides an overview of recent epidemiological and immunopathologic evidence concerning the link between upper and lower airways in allergic disease and its therapeutic implications.

Impact of nasal condition on self-assessed disease control and treatment satisfaction in patients with asthma complicated by allergic rhinitis

BACKGROUND

Bodies of evidences have suggested that upper and lower airways are intricately interconnected with each other in patients with allergic airways diseases, however, few data are available concerning the impact of allergic rhinitis on self-assessed asthma condition and treatment satisfaction. The present study was conducted to clarify the association between nasal condition and self-assessment of asthma control and treatment satisfaction.

METHODS

Adult patients with asthma were consecutively recruited for a systematic self-administered questionnaire to obtain information on nasal condition, self-perceived condition of asthma, and asthma treatment satisfaction.

RESULTS

3,140 adult patients with asthma completed the questionnaire, and of these 634 patients (mean age:53.1, 389 female) had physician-diagnosed allergic rhinitis. There were significant correlations between nasal symptoms (sneeze, rhinorrhea, nasal obstruction) and self-perceived asthma condition (limited daily activity, wheeze, dyspnea/chest tightness, cough, sputum, sleep disturbance, overall asthma condition). Patients who considered their overall nasal condition as unfavorable or bad were more likely than those who considered their condition as good or favorable to be dissatisfied with asthma treatment (p<0.01).

CONCLUSIONS

Nasal condition is closely associated with self-assessed asthma condition and asthma treatment satisfaction. Controlling allergic rhinitis is critical to attain optimal management of asthma in patients complicated by allergic rhinitis.

Quality of life in allergic rhinitis: relationship with clinical, immunological, and functional aspects

BACKGROUND

The relationship among nasal obstruction, T-helper type 2-dependent inflammation, nasal airflow limitation, and reversibility to the nasal decongestion test has been evidenced in allergic rhinitis (AR). Moreover, quality of life (QoL) has been widely evaluated in AR and its evaluation is considered in numerous trials.

OBJECTIVE

The aim of this cross-sectional study was to identify the QoL as measured by the Quality of Life Questionnaire in a population of patients with AR and to compare it with clinical, immunological, and functional parameters.

METHODS

One hundred and twenty-three patients with persistent AR were prospectively and consecutively evaluated. Clinical evaluation, skin prick test, nasal scraping for cytology, rhinomanometry, decongestion test, and QoL questionnaire were performed in all subjects.

RESULTS

There was a significant relationship among QoL and functional and immunological parameters. Particularly, the multivariate analysis showed that having more than two sensitivities was a determinant of the QoL. The eosinophil count was significantly associated with QoL as well as the baseline nasal flow (mL/s) with the eye symptoms scale only.

CONCLUSIONS

This study provides the first evidence that QoL in AR is strictly associated with allergic inflammation and eye symptoms significantly contribute to impairment of QoL. QoL, moreover, represents an important aspect to consider in managing patients with AR as it has a relationship with clinical, immunological, and functional parameters.

Rodent models of allergic rhinitis: relevance to human pathophysiology

Rodent models of allergic airways disease employ a wide range of test allergens, sensitization and provocation protocols, animal strains, and experimental endpoints. Studies of experimental asthma, especially the use of murine models, have contributed significantly to the understanding of the genetics and immune-mediated pathophysiology of pulmonary airways during allergy. By comparison, rodent models of allergic rhinitis are less well developed. Recent interest in the potential mechanistic links between asthma and allergic rhinitis has increased the need for relevant animal studies directed at upper airways responses. Specifically, the nature of nasal airway remodeling in response to chronic activation of allergic pathways and its relationship to airway occlusion is not well described. This cursory review discusses current approaches to assessing nasal obstruction in rodent models, and how the histopathologic analysis might be improved to facilitate understanding of the pathogenesis of allergic rhinitis in humans.

Spleen tyrosine kinase (Syk) as a novel target for allergic asthma and rhinitis

Allergic asthma and rhinitis are prevalent diseases in the modern world, both marked by inflammation of the airways. The spleen tyrosine kinase (Syk) plays a critical role in the regulation of such immune and inflammatory responses. Although Syk is best known as a key component of immunoreceptor signalling complexes in leukocytes, recent studies demonstrated Syk expression in cells outside the haematopoietic lineage. Moreover, in recent years, it has been established that Syk is involved in various signalling cascades including those originating from integrin and cytokine receptors. Thus, Syk likely has a much wider biological role than previously recognised. Specific inhibition of Syk using aerosolised antisense oligonucleotides in liposome complexes significantly decreased lung inflammatory responses in experimental asthma and acute lung injury models. In addition, pharmacological inhibitors of Syk have been recently developed with potential for use as therapeutics. However, in the development and the rational delivery of drugs targeting Syk, it is important to consider the multiple cell types that express this kinase and the potential effects of its inhibition on various physiological functions. This review focuses on the recent data and the emerging ideas about Syk as a therapeutic target.

Combined mediator blockade or topical steroid for treating the unified allergic airway

BACKGROUND

Asthma and allergic rhinitis are manifestations of a single unified allergic airway, for which the best treatment is uncertain.

OBJECTIVE

To compare the anti-inflammatory efficacy in the unified allergic airway of combined oral mediator antagonism and combined topical steroid.

METHODS

Subjects with asthma and perennial allergic rhinitis entered a randomized double blind crossover study comparing montelukast 10 mg and cetirizine 10 mg to extra-fine inhaled beclomethasone 400 mcg/day and intranasal beclomethasone 200 mcg/day, each taken once daily for 2 months, after 2-week placebo washouts. Measurements were made after each washout and randomized treatment, comprising: methacholine PC20, exhaled and nasal nitric oxide, blood eosinophils and eosinophilic cationic protein, symptoms, lung and nasal function tests.

RESULTS

Seventeen patients completed per protocol. For PC20 and exhaled nitric oxide, only combined topical steroid produced improvements (P < 0.005) from placebo baseline. Combined steroid was superior by a 0.93 (95% CI 0.14-0.93, P < 0.05) doubling dilution difference for PC20 and a 0.99 (95% CI 0.9-15.1, P < 0.01) doubling difference for exhaled nitric oxide. Both treatments attenuated eosinophils and eosinophilic cationic protein, and reduced nasal symptoms (P < 0.05). Only steroid improved nasal nitric oxide (P=0.05) and asthma symptoms (P < 0.05). Neither treatment affected lung or nasal function tests.

CONCLUSION

Combined topical steroid and combined mediator antagonism both attenuated systemic inflammation in the unified allergic airway, but only the former reduced bronchial and nasal inflammatory markers. The relevance of this to exacerbations and airway remodelling needs to be defined.

Nasal resistance and allergic inflammation depend on allergen type

BACKGROUND

Allergic rhinitis is characterized by inflammatory cell infiltrate and increased nasal airflow resistance.

OBJECTIVE

The aim of this study was to evaluate the relationship between sensitization type, inflammatory cell pattern, and nasal airflow resistance in a group of rhinitics with monosensitization.

METHODS

Seventy-seven subjects (40 males and 37 females, with a mean age of 33 +/- 4.4 years) suffering from allergic rhinitis were studied. Skin prick test, nasal cytology and electronic rhinomanometry were assessed in all subjects.

RESULTS

The number of subjects monosensitized to house dust mites was 23, to grasses 20, to cypress 17, to Parietaria 11, and to olive tree 6. Significant differences were observed between each type of allergen sensitization concerning both the nasal airflow resistance (p = 0.002) and the nasal cytology pattern: eosinophils (p = 0.004), degranulated eosinophils (p = 0.002), mast cells (p = 0.006) and degranulated mast cells (p = 0.008). Furthermore, goblet cells were higher in house dust mite-sensitized subjects compared with the pollen-sensitized group (p = 0.018), in which a prevalence of eosinophils, degranulated eosinophils, mast cells and degranulated mast cells was observed (p = 0.049, p < 0.001, p = 0.022 and p = 0.007, respectively). Nasal resistances were higher in the pollen group (p = 0.001).

CONCLUSIONS

This study provides evidence that inflammatory cell pattern and nasal resistance depend on the type of allergen sensitization.

Pathophysiology of nasal obstruction and meta-analysis of early and late effects of levocetirizine

Nasal obstruction, also referred to as congestion, blockage or stuffiness, is a crucial symptom in allergic rhinitis (AR) and may affect sleep as well as quality of life. Early- and late-phase-allergic reactions both contribute to nasal obstruction, although it primarily represents a major symptom in the chronic allergic reaction. A complex network of inflammatory and neurogenic phenomena relates to chronic nasal obstruction, including the subepithelial accumulation of inflammatory cells, particularly mast cells and eosinophils, and the release of neuropeptides. Nasal obstruction is a difficult-to-treat symptom. Vasoconstrictors (decongestants) and intranasal corticosteroids, due to their anti-inflammatory properties, have mainly been used for relieving the nasal passages from the congested mucosa. However, there is accumulating evidence recently that the latest-generation potent antihistamines have decongestant properties in AR. This paper aims to review the pathophysiologic background of nasal obstruction and the evidence for an antihistamine, levocetirizine, in relieving nasal congestion. A meta-analysis on the early and late effects of levocetirizine on nasal obstruction under artificial and natural allergen exposure conditions is presented, demonstrating convincingly that levocetirizine shows a consistent effect on nasal obstruction as early as over the first 2 h and sustained over 6 weeks.

Review of desloratadine for the treatment of allergic rhinitis, chronic idiopathic urticaria and allergic inflammatory disorders

Desloratadine is a once-daily, non-sedating, non-impairing, selective histamine H1-receptor antagonist. It relieves the symptoms of seasonal allergic rhinitis (including nasal obstruction and congestion, and morning symptoms), perennial allergic rhinitis and chronic idiopathic urticaria by blocking multiple critical steps in the systemic allergic cascade and downregulating key allergy-induced inflammatory mediators. It also relieves asthma symptoms and decreases rescue medication use in patients with seasonal allergic rhinitis and comorbid asthma. Numerous clinical studies have demonstrated that desloratadine is safe, well tolerated and free of serious cardiac effects. Pharmacokinetic studies have demonstrated a low propensity for drug-drug or drug-food interactions. This review outlines the mechanism of action, efficacy and safety of desloratadine for the treatment of allergic inflammatory disorders.

Association between response to decongestion testing and sensitizations and allergic inflammation

BACKGROUND

Rhinomanometry is used to measure nasal airflow, which is frequently impaired in allergic rhinitis (AR). Decongestion testing consists of spraying an intranasal vasoconstrictor drug to evaluate recovery of nasal airflow.

OBJECTIVE

To evaluate the relationships among type and number of sensitizations, nasal airflow recovery after topical vasoconstrictor drug use, and allergic inflammation.

METHODS

A total of 123 patients (112 men and 11 women; mean +/- SD age, 22.9 +/- 5.7 years) were studied: 40 with perennial AR (PAR), 43 with mixed AR (MAR), and 40 with seasonal AR (SAR). Patients with anatomic nasal defects were excluded. Total symptom scores (including nasal itching, sneezing, rhinorrhea, and nasal obstruction), sensitizations, nasal eosinophils, and cytokines (including interleukin 4 [IL-4], IL-5, and interferon-gamma) were evaluated. Electronic rhinomanometry and decongestion testing were performed in all the patients.

RESULTS

After administration of a topical nasal vasoconstrictor agent, mean nasal airflow significantly increased from 471 to 580 mL/s (P < .001). In 12 patients (3 with PAR, 3 with MAR, and 6 with SAR), no increase was shown. Changes from baseline were different in the PAR, MAR, and SAR populations (PAR vs MAR, P < .001; PAR vs SAR, P < .001; and MAR vs SAR, P = .25). Type of sensitization (MAR, PAR, or SAR), concentration of eosinophils, and levels of IL-4, IL-5, and interferon-gamma were associated with nasal airflow recovery of at least 120 mL/s.

CONCLUSIONS

This study provides the first evidence of a different response to decongestion testing taking into consideration the type of AR.

Impact of nasal congestion on quality of life and work productivity in allergic rhinitis: findings from a large online survey

BACKGROUND

Allergic rhinitis is the most common allergic disease in the US. The predominant symptom of this condition is nasal congestion, which has a significant impact on quality of life and work productivity. This large survey was conducted to determine the impact of nasal congestion on the above parameters in individuals with allergic rhinitis, and treatment patterns for this symptom.

METHODS

Participants were recruited voluntarily via telephone surveys and internet advertisements. Respondents with nasal congestion as a symptom of their allergic rhinitis (or who were primary caregivers to a child with nasal congestion associated with allergic rhinitis) were eligible for participation and completed a 52-question internet survey. Data were normalized to the US adult population using a weighting algorithm.

RESULTS

Of the 2355 individuals with allergic rhinitis screened for participation in the survey, 2002 (85%) had nasal congestion. This was considered severe by 40% of respondents, compared with fewer than 30% who considered any other individual allergy symptom to be severe. Nasal congestion was the symptom that most adults and children wished to prevent, and it affected most respondents at work or school, had a notable emotional impact, and interfered with their ability to perform daily activities. Only 13% of participants receiving allergic rhinitis medication of any type, including over-the-counter medications, claimed to be very satisfied with treatment, and only 20% adhered completely to prescribing instructions. Although intranasal corticosteroids are recommended as first-line therapy for nasal congestion, only 30% of respondents with severe nasal congestion received treatment with intranasal corticosteroids.

CONCLUSIONS

Nasal congestion affects most individuals with allergic rhinitis, and has a notable impact on quality of life, emotional function, productivity, and the ability to perform daily activities. Patients need to be better educated on the appropriate use of medications, particularly intranasal corticosteroids, to manage their nasal congestion.

Nasal airflow recovery after decongestion test is associated with bronchial hyperreactivity in patients with allergic rhinitis

BACKGROUND

The decongestion test involves spraying an intranasal vasoconstrictor drug to evaluate the recovery of nasal airflow.

OBJECTIVE

The aim of this study was to assess the relationship between pulmonary function (assessed by spirometry and methacholine challenge) and nasal airflow recovery after a topical vasoconstrictor had been administered in patients with allergic rhinitis (perennial, seasonal, or mixed allergic rhinitis).

METHODS

A total of 150 subjects were studied. The total symptom score, sensitization, and pulmonary function were all assessed. All subjects underwent rhinomanometry and the decongestion test.

RESULTS

Univariate analysis revealed that nasal symptoms and spirometric parameters (except FEF(25-75) in subjects with seasonal allergic rhinitis) were not. Only bronchial hyperreactivity, assessed by methacholine challenge, proved to be significantly (and independently) associated with outcome (OR 1.45, P = 0.025).

CONCLUSIONS

This study provides the first evidence of an association between a positive response to the decongestion test and bronchial hyperreactivity, assessed by methacholine challenge, in patients with allergic rhinitis.

Decongestion test in patients with allergic rhinitis: functional evaluation of nasal airflow

BACKGROUND

Rhinomanometry measures nasal airflow that is frequently impaired in allergic rhinitis. Decongestion tests consist of spraying an intranasal vasoconstrictor drug to evaluate the reversibility of nasal airflow limitation. The aim of this study was to evaluate the decongestion test in patients with seasonal allergic rhinitis (SAR) caused by pollen sensitization, perennial allergic rhinitis (PAR) caused by sensitization to perennial allergens only, or mixed allergic rhinitis (MAR) caused by sensitization to both allergens.

METHODS

One hundred twenty-three subjects (112 men and 11 women, mean age, 22.9 +/- 5.7 years) were studied; 40 subjects had PAR, 43 subjects had MAR, and 40 subjects had SAR. Total symptom score (including: nasal itching, sneezing, rhinorrhea, and nasal obstruction) was assessed. Rhinomanometry and decongestion tests were performed in all subjects.

RESULTS

Nasal symptom severity was superimposable in the three groups (p was not significant). After decongestion tests, an increase of nasal airflow and a decrease of nasal resistance was shown in PAR (p < 0.01), MAR (p < 0.001), and SAR subjects (p < 0.001). The intergroup analysis showed that SAR patients had less reversibility than PAR (p < 0.01).

CONCLUSION

This study provides the first evidence of the different response to decongestion tests, taking into consideration the causal allergens.

The role of the eosinophil in nasal diseases

PURPOSE OF REVIEW

The eosinophil is involved in physiologic and pathologic processes, such as asthma, parasitic diseases, granulomatous disorders, fibrosis, malignant tumors and several sino-nasal diseases.

RECENT DEVELOPMENTS

Recent data on the structure and function of the eosinophil provides additional information regarding the pathophysiology and the treatment options of these diseases. In this paper the most recently acquired data on the role of the eosinophil in allergic rhinitis (with or without bronchial asthma), chronic sinusitis (with or without nasal polyposis) and allergic fungal sinusitis are reviewed.

SUMMARY

The data provides evidence regarding the pivotal role of the eosinophil in sino-nasal diseases. Possible ways to target the eosinophils are discussed.

Interleukin-13-dependent bronchial hyper-responsiveness following isolated upper-airway allergen challenge in a murine model of allergic rhinitis and asthma

BACKGROUND

We have previously shown that isolated allergic sensitization and challenge of the upper airway results in lower-airway inflammation, which supports the concept of the united airways.

OBJECTIVE

This study investigates the hypothesis that isolated upper-airway allergic sensitization is sufficient to induce bronchial hyper-responsiveness (BHR), characteristic of asthma, and that IL-13 is an essential mediator in both the upper and lower airways.

METHODS

BALB/c mice were sensitized and challenged by intranasal instillation of allergen ovalbumin (OVA) using our standard protocol. BHR to methacholine was determined and inflammation in nares and lung was assessed.

RESULTS

Isolated intranasal application of allergen in awake animals resulted in almost exclusive deposition in the upper airways while in anaesthetized mice there was almost equal distribution in the upper and lower airways. We have demonstrated significant BHR to methacholine challenge in animals receiving OVA only in the upper airway. Also noted was concomitant increase in eosinophilic infiltrates in lung and nares as well as increased granulocytes and IL-13 levels in bronchoalveolar lavage (BAL) fluid. Using a polyclonal anti-IL-13 antibody we have shown inhibition of airways inflammation, both in nares and in lung with significant reduction of granulocytes in BAL from anti-IL-13 treated mice (P<0.0001). Anti-IL-13 treatment also abrogates allergen-induced BHR (P<0.01).

CONCLUSION

These data suggest that isolated upper-airway allergen deposition initiates allergic responses along the entire airway. IL-13 mediates both airway inflammation and BHR and may play a role in the communication between the upper and lower airways.

Atopic march: link to upper airways

PURPOSE OF REVIEW

This review examines the role of the upper airways in the atopic march. Evidence examining the theory that allergic rhinitis precedes asthma will be discussed. In addition, the role of allergic rhinitis as an end point in the atopic march will be reviewed.

RECENT FINDINGS

Ciprandi and colleagues found that nasal symptoms, airflow and markers of inflammation (eosinophils, cytokine levels) directly correlated with lower airway markers. This confirms previous studies finding that many patients with allergic rhinitis have lower airway hyperreactivity or bronchial hyperresponsiveness and the link between upper and lower airways. Leynaert and colleagues questioned over 90 000 individuals and found that patients with rhinitis have increased risk for asthma and lower airway reactivity compared with patients without rhinitis. In the German Multicenter Atopy Study, a longitudinal study of 1300 children, patients with atopic dermatitis were found to have increased risk for asthma at 7 years of age. Patients with atopic dermatitis and no wheezing in the first 3 years, however, did not have an increased risk for developing current wheezing or bronchial hyperresponsiveness at 7 years of age. It was proposed that atopic dermatitis and asthma are linked, but atopic dermatitis does not precede asthma.

SUMMARY

Allergic rhinitis is a risk factor for asthma and can precede asthma in the atopic march.

Early bronchial airflow impairment in patients with persistent allergic rhinitis and bronchial hyperreactivity

BACKGROUND

Allergic rhinitis and its impact on asthma (ARIA) document underlines the link between upper and lower airways. Patients suffering from allergic rhinitis frequently (up to 80%) show bronchial hyperreactivity (BHR).

OBJECTIVES

This study aimed at evaluating a group of subjects suffering from persistent allergic rhinitis, with BHR but with nasal symptoms only, to investigate the type and intensity of nasal symptoms, nasal and bronchial airflow, and BHR grade during the pollen season.

METHODS

One hundred and twenty one polysensitized rhinitics were investigated. Total symptom score (TSS) was assessed in all patients. Rhinomanometry, spirometry and methacholine bronchial challenge were performed in all patients.

RESULTS

65 (53.7%) patients had impaired FEF 25-75 values. TSS correlated with nasal airflow (P<0.001) and BHR grade (P<0.001). Nasal airflow correlated with FEF 25-75 values (P<0.05) and BHR (P<0.001). FEF 25-75 values correlated with FEV(1) levels (P<0.003), BHR grade (P<0.001), and nasal obstruction symptom (P<0.05). Severe BHR correlated with FEV(1) (P<0.05) and FEF 25-75 (P<0.03) values, nasal airflow (P<0.05) and nasal symptoms (P<0.001).

CONCLUSIONS

This study evidences that early bronchial impairment is frequently detectable in patients with persistent allergic rhinitis and BHR. Moreover, nasal function is strictly related with bronchial calibre and BHR grade. Therefore, careful evaluation of lower airways should be investigated in all rhinitics as suggested by the ARIA document.

Nasal eosinophils display the best correlation with symptoms, pulmonary function and inflammation in allergic rhinitis

BACKGROUND

The pathogenesis of allergic rhinitis and its link with asthma are well known. Nevertheless, a complete cross-sectional evaluation of the usually available clinical, functional and immunological parameters has never been made. We assessed nasal symptoms and flow, cytology, cytokines, pulmonary function and methacholine positivity in a large number of patients with pure pollinosis.

METHODS

Young men presenting at a military hospital for routine follow-up were recruited for the study. They had to suffer from rhinitis alone (without asthma) for at least 2 years and had to have a positive skin prick test to pollens only. During the pollen season, they underwent symptom evaluation, measurement of nasal flow, nasal scraping and lavage (cell count and assay for IL-4, IL-5, IL-8 and IFNgamma), pulmonary function tests and methacholine challenge.

RESULTS

Fifty subjects (23.7+/-4.9 years old) were enrolled. All patients had high clinical scores (9.5+/-1.6) and inflammatory cells (eosinophils: 10.5+/-4 and neutrophils 21.3+/-6) and low nasal flow (482+/-111 ml/s). We found that the number of eosinophils in nasal scrapings highly correlated with all the above-mentioned parameters, including nasal flow, cytokines and spirometric values. A significant positive correlation was found between all inflammatory cells and all cytokines. IL-8, IL-4 and neutrophils displayed only a partial correlation with pulmonary parameters (FEV1, FVC and FEF25-75%), at variance wit IL-5 and eosinophils. Methacholine test positivity significantly correlated with the number of eosinophils in the nasal smear.

CONCLUSION

Eosinophils in the nasal smear display the best correlation with all the clinical and immunological parameters in allergic rhinitis and also correlate well with methacholine response.