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Allergic rhinitis-of course there is a differential diagnosis_

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					Allergic rhinitis-of course there
is a differential diagnosis!
                 R. Masekela

                 PMG meeting Spier May 2010
Obama dilemma!
Scope
• Allergic rhinitis
    ▫   Definition
    ▫   Prevalence
    ▫   Diagnosis
    ▫   Therapy
    ▫   Complications
•   Differential diagnosis of AR
•   PCD
•   Vasomotor rhinitis
•   Atrophic rhinitis
•   Conclude
Allergic Rhinitis is a Disease
  with Nasal Inflammation
      Classification of allergic rhinitis
The WHO ARIA workshop suggested a new classification of AR based on FREQUENCY and SYMPTOM
SEVERITY as these are the major factors Involved in determining treatment 2

      Intermittent symptoms                                         Persistent symptoms
  <4 days per week                                         >4 days per week
  Or <4 weeks                                              And >4 weeks


                 Mild                                                Moderate/Severe
  Normal sleep                                                     One or more items
  Normal daily activities,                                   Abnormal sleep
   sport, leisure                                             Impairment of daily
                                                               activities, sport, leisure
  Normal work and school
                                                              Problems caused at work
  No troublesome symptoms                                     or school
                                                              Troublesome symptoms

                                           Adapted from Bousquet J et al. J Allergy Clin Immunol 2001;108:S147–S334.
                                            ARIA in Collaboration with WHO. Allergy 2002;57:841–855
Changing Prevalence of AR in African
Adolescents
  • Prevalence of AR in children has been increasing
  • Zar HJ et al. conducted a study to assess the time trends in the
    symptoms of AR among South African adolescents:

    -    Study compared cross-sectional data from ISAAC
         phase I (1995) and ISAAC phase II (2002)
    -    Outcome : The 12 month prevalence of symptoms of
         - Allergic Rhinitis:           30.4% vs 38.5%

  • Outcome: Limitations of daily activity affecting QoL
        - Nasal symptoms:                 22.3% vs 37.8%




                                ISAAC – International Study of Asthma and Allergies in Childhood
                                Zar HJ et al. Pediatr Allergy Immunol 2007;18:560–65
Prevalence of symptoms of Allergic Rhinoconjunctivitis
– ISAAC Phase III in Africa
ISAAC Phase III Study conduced in Africa determined the prevalence of
allergic rhinoconjunctivitis in 22 centres among 16 countries


                                                  •Cape Town - 20.7%
                                                  •Polokwane - 18.2%
                                                  •Brazzaville - 33.3%
                                                  •Cote d’Ivoire - 27.6%
                                                  •Nairobi - 19.8%
                                                  •Kinshasa - 11.8%
                                                  •Reunion Island 27.3%




                                                         Ait-Khaled et al.Allergy 2007;62:247–258
  The Symptoms of Allergic Rhinitis


Early Phase
                  Rhinorrhoea
  Allergic
 Response         - secretion of watery mucus

                 Sneezing
   Allergic
                  - sensory nerve stimulation
Inflammation
                  Nasal blockage
                  - oedema
                  - vasodilatation
  NHR             - venous congestion
Diagnostic testing
• Allergy testing
     Skin Prick Test
     ImmunoCAP RAST tests


• Non- IgE mediated allergy testing for foods?
QOL

• 50% nasal congestion predominant¹

• Effect of pro-inflammatory cytokines on sleep and
  fatigue²

• Difficulty with schoolwork and psychomotor
  performance³

                        1. Stull DE et al. Curr Med Res Opin 2007;23:811-9
                              2. Stuck BA e al. JACI 2004;11:663-8
                                  3. Meltzer EO. JACI 2001;108:S45-53
                                      4.
Mediator                                  Effect on sleep
Histamine                                 Balance between wakefulness and
                                          arousal.  nasal obstruction ,
                                          rhinorrhoea and pruritis
Cysteinyl leukotrienes                     Slow wave sleep ,sleep disordered
                                          breathing, obstruction and rhinorhoea

IL-1                                       Latency to REM and  REM
                                          duration
IL-4                                      Latency to REM and  REM
                                          duration
IL-10                                      Latency to REM and  REM
                                          duration
Bradykinin                                 Sleep apnoea, nasal obstr and
                                          rhinorhoea
Substance P                                latent to REM and arousal. 
                                          obstruction

                         Craig et al. Curr Allerg Asthma Rep 2010;10:113-121
Allergic rhinitis can have an impact on various aspects
                      of the daily life

                             Sleep
                                           Emotional
                Work                       wellbeing

                         ALLERGIC
                          RHINITIS
                                            Related
                School                     Allergic
                             Social        diseases
                              Life


  The impairment of different domains of the daily life is judged
  according to patients’ age, personal habits as well as social,
                professional and cultural needs
Allergic Rhinitis Affects The Quality Of Sleep (n
                    = 1181) (%)
              76.6
        80

        70

        60

  %
        50

        40

        30

        20

        10

         0

                     Affect sleep quality   Every night   Less than once a week   Less than once a month




      Green RJ, et al. Prim Care Respir J 2007;16:299-303
Complications of AR
Adherence issues
• Easy to use

• Affordable

• Side effect profile

• Tolerated
Therapy
• Intranasal corticosteroids (first line)

• Local chromones

• Antihistamines

• LTRA

• Immunotherapy

• AVOIDANCE of triggers
Differential diagnosis
   Non                              Systemic       Structural
                  Drugs
 allergic                           disorders       factors

                      Rhinitis       Hypothyroid
  Vasomotor
                   medicamentosa        ism


                                      Wegener’s
    Chronic
                   Drug induced –    granulomato
    sinusitis
                     OCP, anti-          sis
                    hypertensives
  Non allergic
                                       Sjogrens
  rhinitis with
                                      syndrome
  eosinophillia


   Gustatory
    rhinitis



    Atrophic
Primary ciliary dyskinesia
• Recurrent URT/LRT infections, glue ear ,
  hearing impairment, neonatal cough and NICU
  admission.

• Heterotaxies

• CBF < 11Hz suggestive (12.9% missed)

• Nasal FeNO helpful screening tool
                    Stannard WA et al. AJRCCM 2010;181:307-314
                                                                 Mutations   Mutation Detection Frequency
Gene Symbol/   % of All PCD     Test Method                      Detected    by Gene and Test Method

Locus Name
                                Targeted mutation analysis 1 /
                                sequence analysis of select      Sequence
DNAI1/ PCD1    <2%-10%          exons 2                          variants    TBD
                                Targeted mutation analysis 1 /
                                sequence analysis of select      Sequence
DNAH5/ PCD3    15%-28%          exons 3                          variants    TBD

TXNDC3/ PCD6   2- 4%            Direct DNA 5                     N/A         N/A

DNAH11/ PCD7   N/A 6            Direct DNA 5                     N/A         N/A

DNAI2 / PCD9                  2% Direct DNA 5                    N/A         N/A
C14orf104
(KTU/PF13)/
PCD10          ~2%              Direct DNA 5                     N/A         N/A

RSPH4A/ PCD11 NA 7              Direct DNA 5                     N/A         N/A

RSPH9/ PCD12   NA 7             Direct DNA 5                     N/A         N/A
Treatment
• Antibiotics for RTIs

• ? Prophylactic antibiotics

• Immunizations

• Counselling
Atrophic rhinitis
• Atrophy of the nasal cavity

• More common in pubertal females

• Large nasal cavity with foul smelling crusts and
  anosmia ( 2◦ nerve atrophy)

• Nasal obstruction despite large nasal cavity
Atrophic rhinitis
• HERNIA
 ▫   Hereditary factors
 ▫   Endocrine: pubertal disorder
 ▫   Racial: caucasians and asians
 ▫   Nutritional deficiency: Vit A, D, Iron
 ▫   Infection: klebsiella, diphtheroids, E.Coli
 ▫   Autoimmune:SLE

 Other: secondary to syphillis, leprosy,
  rhinoscleroma
Vasomotor rhinitis
• Chronic sneezing, rhinorrhoea, nasal
  congestion and PND in absence of specific
  cause

• Increase sensitivity to environmental factors
  e.g. strong odors, perfumes, climate change
  and pollution

• Mechanism: ? Nerve dysfunction/ ?autonomic
  dysfunction/ immunologic

        Parranaik D et al. Curr Allerg Asthma Rep 2010;10:84-91
Treatment
• Topical corticosteroid and topical antihistamine
  (Azelastine)

• Topical anti-cholinergics (ipratropim bromide
  0.03%) if rhinorhoea predominant

• Adjuncts:
 ▫ Short course oral decongestant
 ▫ Normal saline rinses
Rhinitis medicamentosa
• Abuse or overuse of nasal decongestants

• Recurrent obstruction and rhinorhoea
Diagnostic pitfalls
• Growth parameters

• Drugs

• Complications
Conclusion
• Allergic rhinitis is not an innocuous condition

• There is a differential diagnosis to AR

• Quality of life issues need to be addressed both
  in the diagnosis and management of patients.

• Newer agents have shown some benefit in
  management of AR
Acknowledgements
•   Prof RJ Green
•   Dr O Kitchin
•   Dr C Els
•   Dr D White
•   Dr M Kwofie-Mensah
•   Chest and Allergy Clinic staff
Questions??

				
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posted:11/22/2012
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