Allergic Rhinitis Ebook
There are many occupational allergic hazards which can give rise to allergic rhinitis and, more important, to the associated asthma. Workers dealing with castor beans (Ricin spp.), whether in the fields, during transport, at the dockside or in ships, are particularly at risk. They are such a strong sensitizers that they will cause allergic inhalent problems to the so-called 'normal' population when downwind from a castor bean factory or when actively working with the beans.
It is remarkable that in 1934 it was found that 3.5 of the Japanese population resident in southern California were found to have allergic rhinitis due to pollen, a disease that had never been recognized in Japan. However, in 1986 not only was the increase recognized, but an incidence as high as 33.3 for children aged between 6 and 17 years had been noted. The major allergen in Japan comes from trees - the Japanese cedar tree. The frequency of allergy to this particular pollen is more common in people living within 50-100 m of a motorway, compared with those living in the country who are surrounded by trees. In the UK, it has been shown that the number of people consulting their doctors for seasonal hayfever almost doubled between 1970 and 1981. The increase is still continuing and is occurring in all age groups, but between 1961 and 1985 records on the content of the air over Central London have shown a decline in the cumulative grass pollen count. This is largely because fewer...
The classic symptoms of acute sinusitis include pain overlying the affected area, decreased sense of smell, fever, headache, and purulent nasal discharge. These symptoms are often difficult to differentiate from upper respiratory infection or allergic rhinitis, and have been found to be poor indicators of sinus infection. The best indicators of bacterial sinusitis are, in decreasing order of predictive value, maxillary toothache, mucopurulent discharge, poor response to nasal decongestants, and abnormal transillumination.1 l6 Although maxillary toothache is a good predictor of acute sinusitis, it is only found in 11 percent of patients with the disease. 15
III antigens, most information is available about Dei. p 1. The fecal pellets are relatively large, 10-30 jxm, and cause allergic conjunctivitis as well as allergic-rhinitis and asthma. Airborne levels of Der. p I give a more appropriate idea of allergen level than arc-obtained in dust, where the highest concentrations are in the mattress and bedding. The allergens arc-also present in soft furnishing and carpets and especially toys. Many methods used to control house-dust mite rhinitis have been amazingly disappointing. Specific injection treatment is indicated when symptomatic treatment is not giving enough help, especially when symptoms arc increasing in severity with time. The UK was the first to use this method of treatment in 1911, but since 1986 because the Committee on the Safety of Medicines decided that the treatment was both dangerous and also ineffective, their recommendations mean that the UK has virtually ceased to use this form of treatment. The pros and cons of such...
Skin prick tests are mainly used in research studies. The results of skin tests cannot be taken alone, and standard textbooks on allergy acknowledge that ''the proper interpretation of results requires a thorough knowledge of the history and physical findings.'' The problems in clinical practice are, for example, whether or not a subject with atopic disease (eczema, asthma, or hay fever) or symptoms suggestive of food intolerance will benefit from attempts to avoid certain foods or food additives. However, skin prick test results are unreliable predictors of response to such measures.
Randomized, double-blinded, placebo-controlled clinical trials, while generally regarded as the gold standard for scientific proof of the efficacy and safety of most new drugs, are limited in their application by ethical, scientific, and practical considerations (Fig. 8.38). In certain instances, while generally accepted effective standard treatment does exist, withholding it and using placebo may be acceptable, as in, for example, antihistamines in allergic rhinitis. In other clinical settings as, for example, in virtually all serious infections, the sequelae of withholding treatment would be medically unacceptable, thus mandating the use of a positive control of currently available approved therapy.
Reinjcction of fish antigen immediately triggered a wheal and a flare at the site of reinjection. This observation goes back to 1921. It is surprising that the term allergy or atopy (altered reactivity) has become synonymous with a type I hypersensitivity only in more recent times when the term 'allergen' was introduced for proteins and chemicals responsible for this reaction, and the term 'anaphylaxis' was established for the resulting generalized immune reaction. The localized form of anaphylaxis is exemplified by hay fever, asthma, eczema and urticaria (skin wheals). The systemic anaphylaxis characterized by sudden shock and dyspnea, frequently leading to death, occurs in extremely sensitive individuals.
On the whole, allergy is a concern in the more highly industrialized parts of the world, where immunology is mainly practised and where intensive efforts are being made to understand the 'pathogenesis' of allergy. Allergic conditions include hayfever or rhinitis (the most common), asthma, atopic dermatitis, food allergy and allergic uveitis (affecting the eyes). Anaphylactic shock is the only manifestation of the response that is systemic in nature, and thus differs from the others, which predominantly affect single organs. There has been an alarming increase, corresponding to a 10-year doubling rate, in the incidence of allergic disease in the industrialized parts of the world over the last few decades. Now one in five adults suffers from some form of allergy and a similar proportion of children suffer from asthma. IgE is implicated in the pathogenesis of allergy, as a key component in both the afferent (by way of dendritic cells and B cells) and the efferent (by way of mast cells...
Although the majority of anaphylactoid reactions occur unpredictably, certain risk factors have been well documented. Even though these reactions are not true allergic reactions, patients with a history of a previous adverse response to contrast material have a risk of subsequent reaction that is three- to fourfold greater than the general population (Katayama et al. 1990 Morcos and Thomsen 2001). Other important risk factors include asthma and a history of atopy, including hay fever and food allergies (Morcos and Thomsen 2001 Shehadi 1982). In addition, patients treated with -adrenergic blockers and interleukin-2 are at increased risk of acute adverse reactions to CM (Thom-sen and Morcos 2004 Morcos 2005).
Generally, all patients with a history of asthma or atopy (including hay fever and food allergies) have an increased risk of anaphylactic anaphylactoid reactions in the perioperative interval. Risk factors have been clearly demonstrated for two major allergens commonly found in hospital 1. Although reactions to iodinated radiographic CM are not true allergic ones, patients with a history of a previous reaction to contrast material have a three-to fourfold greater risk of subsequent reaction than the general population (Katayama et al. 1990 Mor-cos and Thomsen 2001). Other important risk factors include asthma and a history of atopy, including hay fever and food allergies, increasing the risk of anaphylaxis eight- to tenfold (Morcos and Thomsen 2001 Shehadi 1982). In addition, patients treated with -adrenergic blockers and interleukin-2 are at increased risk of acute adverse reactions to CM (Thomsen et al. 2004 Morcos 2005) (see Sect. 4.7).
Acute or chronic allergic rhinitis due to food is a problem well known to all allergists however, its true incidence is a matter of debate. According to various studies it varies from 2 to 25 of all rhinitis. According to various reports, secretory otitis media, particularly in its chronic form, may possess an allergic component in some cases. This is especially true where there exists a known allergy to foods with respiratory and gastrointestinal symptoms. The verification of such a problem is usually indirect, e.g. a clinical improvement being observed following an exclusion diet. According to some studies, up to 80 of patients with secretory otitis media also have an allergic rhinitis therefore investigation of the rhinitis can eventually help to identify the food component of the otitis. Atopic eczema is largely a disease of children. This clinical form is rather easy to distinguish from other types of eczema, such as contact eczema. The overall incidence of eczema in early...
Atopic eczema is a chronic inflammatory skin condition characterised by an itchy red rash that favours the skin creases such as the folds of the elbows, behind the knees and around the neck. The morphology of the eczema lesions themselves varies in appearance from vesicles to gross lichenification on a background of poorly demarcated redness. Other features such as crusting, scaling, cracking and swelling of the skin can occur.1 Atopic eczema is associated with other atopic diseases such as hay fever and asthma. People with atopic eczema also have a tendency to dry skin, which makes them vulnerable to the drying effects of soaps.
Allergen immunotherapy represents the dominant immunologic, as opposed to environmental or pharmacologic, approach to management of allergic diseases such as allergic rhinitis, conjunctivitis and asthma. It was developed empirically, coincident with the modern-day discovery of allergy by Portier, Richer and von Pirquet. In essence, it involves identification of the allergen(s) to which a patient exhibits immunoglobulin E (IgE)-dependent sensitivity followed by subcutaneous administration of minute amounts of natural extracts containing these allergens. The goal is lasting modification of immune processes responsible for the maintenance of atopic symptoms. Other, infrequently used, forms of desensitization (i.e. IgE-mediated drug reactions)
In insect venom immunotherapy, protection is achieved in well over 90 of subjects following a short (usually several day) course of injections. Efficacy is commonly tested by deliberate administration of an insect sting challenge in the presence of a physician, yielding clear-cut evidence of success or failure. In contrast, the efficacy of immunotherapy for inhalant allergens, used in therapy of allergic rhinitis or allergic asthma, remains controversial. Proponents argue that allergen immunotherapy is highly effective and that the equivocal results are attributable to use of insufficient or poorly prepared allergen extracts, use of inappropriate or insufficiently rigorous criteria for patient selection or unwillingness of patients to complete a sufficiently long course of treatment. They draw support from statistically significant differences that have been observed in a number of parameters measured in randomized, double-blind, placebo-controlled studies. On this basis, the formal...
Clinical diagnosis is straightforward when otological examination shows a fluid level (Fig. 20.2) or bubbles behind the eardrum. In more subtle cases, tympanometric studies may be required. The finding of a flat (type b) tympanogram is diagnostic. Initial treatment of OME should be conservative. Coexisting allergic rhinitis, URTI should be adequately treated. The use of antibiotics is controversial. However if there is any evidence of acute otitis media, a course of antibiotics is advisable. Persistent OME is more effectively treated with myringotomy and insertion of a grommet (Fig. 20.3). In infants and young children, adenoidectomy
Ferns today are the garden's graceful greenery. They are flowerless plants, reproducing by spores (which incidentally do not cause hay fever) rather than seeds. (The asparagus fern with its little white flowers and red berries is actually a member of the lily family.) So we grow them for their elegant foliage of varying heights, shapes, and textures with an ornamental foliar structure that varies from the simple strap-shaped fronds of the Hart's tongue fern (Phyllitis scolopendrium) to the plumose froth of the finely divided British Polystichum setiferum cultivars. While newly planted ferns must be kept moist, established ferns are a low-maintenance delight and, despite their delicate appearance, are tough. Look for rhododendrons to curl and the grass to brown before your ferns will signal trouble. They bring as their gift to the garden the serenity of forest woodlands, peace in a shady nook, and the ability to give a unifying green calm to a colorful garden palette.
The modern history of 'allergens' dates back to 1873, when Charles Blackley showed that wind-borne pollen grains caused the symptoms of June hayfever and that aqueous pollen extracts caused immediate wheal and flare reactions when scratched into the skin of a hayfever sufferer (himself). At the turn of the century, the causative agents of this Showed that windborne pollen grains caused hayfever and that pollen extracts caused wheal and flare reactions when 'scratched' into the skin Defined 'allergy' as supersensitivity to foreign antigens or 'allergens Used desensitizing injections of pollen extracts ('pollen toxin') to treat hayfever Demonstrated familial inheritance of hayfever asthma, i.e. a genetic trait Passive transfer of immediate skin test reactivity using serum from an allergic patient (the P-K test) ingestion of foods, was associated with the clinical symptoms of hayfever, asthma, atopic dermatitis or food allergy, and that these conditions affected 10-20 of the population....
Patients and there is also evidence to suggest that the affinity for these IgG antibodies is lower. In hayfever patients, IgE antibodies to pollen allergens can account for a significant proportion ( 20 ) of the total IgE. IgE antibody responses to food allergens develop within the first few months of life, whereas antibody responses to inhaled allergens develop over the first 2-3 years of infancy. IgG antibody levels rise (up to 50-fold) in patients being treated by immunotherapy using aqueous allergen extracts. A rise in IgG antibody correlates with clinical efficacy in patients with insect venom allergy, but is not significantly associated with clinical improvement with inhaled allergens. Allergic diseases such as hayfever, asthma and atopic dermatitis affect 10-20 of the population. Asthma is the most common chronic disease of children in Western countries and the prevalence of the disease has been increasing. Over the past 5-10 years, the clinical significance of allergens in...
There is a close concordance between asthma, allergic rhinitis and atopic dermatitis the presence of one of these entities increases the relative risk of the other two by 3- to 30-fold over the lifetime of the subject. All three of these diseases are associated with high levels of nonspecific and antigen-specific serum immunoglobulin E (IgE).
The incidence of allergic diseases (hay fever, asthma and eczema) in the population is increasing, possibly caused by increased exposure to indoor allergens, or by the adjuvant effect of atmospheric pollutants such as diesel fumes, or possibly by dietary changes. Disruption of mucosal surfaces, allowing increased antigen entry and IgE production can occur following exposure to pollutants such as sulfur dioxide or during viral infections. Viruses can precipitate allergic symptoms, especially following respiratory syncytial virus infections in childhood.
Since the 1980s there has been a worldwide increase in the prevalence of asthma in both children and adults. This escalating prevalence has led to significant increases in morbidity and mortality due to the disease. It is the most common chronic respiratory disorder, affecting 3-5 of adults and 10-15 of schoolchildren. Half of the people with asthma develop it before age 10, and most develop it before age 30. In childhood, it is twice as common in boys as in girls, but by adolescence equal numbers are affected. Asthma symptoms can decrease over time, especially in children. Many people with asthma have an individual and or family history of allergies, such as hay fever (allergic rhinitis) or eczema. Others have no history of allergies or evidence of allergic problems.
For a long time, allergic rhinitis is classified as seasonal or perennial. More recently, it is being reclassified as intermittent or persistent depending on the total duration of the symptomatic period. Management of rhinitis is dependent on the underlying cause. Superimposed infection is not uncommon and should be treated accordingly.
Throughout junior high school and high school I suffered from bad hay fever. My family doctor prescribed antihistamines for me. They definitely worked, but they made me feel so bad. Finally, I came to prefer the hay fever. I was happier sneezing than being so depressed and logy. Once, while in college, I took a twenty-five-milligram tablet of Thorazine and I was amazed at how similar the effect was to the antihistamines. I hate that feeling. I managed to get rid of most of my allergies by changing my diet and lifestyle. I haven't taken an antihistamine in years. thirty-eight-year-old man, musician
When hayfever is seasonal or environmental, it will almost certainly be allergic, but the first distinction must be made between infectious and noninfectious rhinitis. In both of these types nasal polyps may be present and the patient is often anosmic. Lack of smell (and taste) may be so insidious in onset that only when leading questions are posed from the doctor taking the history may these symptoms be mentioned. In noninfectious rhinitis that is perennial, it may be very difficult to decide whether there is an Consensus Report on the Diagnosis and Management of Rhinitis decided this word should not be used. Clinical examination is not always helpful the nasal mucosa, which may be described as looking 'typically allergic', should be more accurately described as looking pale and wet. Unfortunately allergic causes are not the only factors that may make the mucosa pale and swollen indeed the nasal turbinates may be so swollen that they look like, but are not polyps - they are correctly...
Figure 1 Mechanism of allergic rhinitis. (Reproduced with permission from Durham SR Hypothesis on mechanisms of allergic rhinitis.) To understand the role of different mediators that generate the signs and symptoms of allergic rhinitis, provocation tests with the mediator in question have been done, and the symptoms monitored. The other way to elucidate the problem is to use specific mediator antagonists which should produce further clues as to the effects of the mediator itself. So long as the effect is on the receptor mechanism it will be relevant. This is certainly the case as far as histamine with the antihistamines is concerned. There are variable amounts of histamine in nasal secretions in normal as well as in allergic nasal secretions. During a nasal infection some bacteria will increase the histamine level. Even so, histamine still remains the only mediator that behaves consistently in terms of release with local challenge, as well as producing most of the major symptoms....
The majority of children with atopic eczema appear to grow out of their disease, at least to the point where the condition becomes a problem no longer in need of medical care. A detailed review of prognostic studies reported elsewhere2 concluded that most large studies of well-defined and representative cases suggest that about 60 of childhood cases are clear or free of disease symptoms in early adolescence. However, many such apparently clear cases are likely to recur in adulthood, often as hand eczema. The most consistent factors that appear to predict persistent atopic eczema are early onset, severe widespread disease in infancy, concomitant asthma or hay fever, and a family history of atopic eczema.
If either parent has a history of an allergic disease then siblings are at increased risk of developing allergic disease, which includes eczema, asthma, allergic rhinitis and food allergy (Zeiger and Heller 1995). The risk is greater if either parent is atopic, and increases if both parents are atopic. In children with cows' milk allergy, a family history of atopy in first-degree relatives has been found in 23-80 of cases (Goldman 1963, Ventura 1988, Host 1990). Findings from a Danish study looking at skin reactions to foods are presented in Table 10.14, confirming the association of food allergy and family history of atopy (Kjellman 1983).
Because of the bronchial muscle relaxant effect, caffeine is used in chronic obstructive pulmonary disease and for the treatment of asthma. The use of caffeine in the treatment of children with minimal brain dysfunction, to increase the duration of elec-troconvulsive therapy-induced seizure, for allergic rhinitis, as well as for atopic dermatitis has also been described. Recently, caffeine has been used as a diagnostic test for malignant hyperthermia and in the diagnosis of neuroleptic malignant syndrome, a complication of neuroleptic therapy.
The oral allergy syndrome discussed in Chapter 1 solely involves the oropharynx (mouth, tongue and throat). Patients describe the rapid onset of itching of the mouth and angioedema (swelling of the lips, tongue, palate and throat). This is generally followed by a rapid resolution of symptoms. They are most commonly associated with the ingestion of various fresh fruit and vegetables. Patients with allergic rhinoconjunctivitis ('hayfever') associated with airborne allergens are most commonly afflicted with this problem. Care must be exercised when taking the history that these symptoms were not in fact the herald of more generalised systemic symptoms.
Atopy is the ability to produce a weal-and-flare response to skin prick testing with a common antigen, such as house dust mite or grass pollen. The atopic diseases are asthma (all childhood cases but not all adult cases), atopic eczema, allergic rhinitis, allergic conjunctivitis, and some cases of urticaria.
Contact irritants are the commonest external causes. Hand eczema caused by such irritants, or mild toxic agents, is called irritant contact dermatitis. Causal factors that are less common than irritants are contact allergens. Hand eczema caused by skin contact with allergens is called allergic contact dermatitis. Ingested allergens (for example nickel) may also provoke hand eczema. Water is a contact irritant and thereby an external causal or contributing factor. Being atopic (a tendency to develop asthma, hay fever or eczema) is the major predisposing factor responsible for hand eczema. There are several types of hand eczema of which the cause or predisposing factor is unknown. These (partly overlapping)