Local allergic rhinitis: a new entity, characterization and further studies

Optimal management of allergic rhinitis

Allergic rhinitis (AR), the most common chronic disease in childhood is often ignored, misdiagnosed and/or mistreated. Undertreated AR impairs quality of life, exacerbates asthma and is a major factor in asthma development. It can involve the nose itself, as well as the organs connected with the nose manifesting a variety of symptoms. Evidence-based guidelines for AR therapy improve disease control. Recently, paediatric AR guidelines have been published by the European Academy of Allergy and Clinical Immunology and are available online, as are a patient care pathway for children with AR and asthma from the Royal College of Paediatrics and Child Health. Management involves diagnosis, followed by avoidance of relevant allergens, with additional pharmacotherapy needed for most sufferers. This ranges, according to severity, from saline sprays, through non-sedating antihistamines, oral or topical, with minimally bioavailable intranasal corticosteroids for moderate/severe disease, possibly plus additional antihistamine or antileukotriene. The concept of rhinitis control is emerging, but there is no universally accepted definition. Where pharmacotherapy fails, allergen-specific immunotherapy, which is uniquely able to alter long-term disease outcomes, should be considered. The subcutaneous form (subcutaneous immunotherapy) in children has been underused because of concerns regarding safety and acceptability of injections. Sublingual immunotherapy is both efficacious and safe for grass pollen allergy. Further studies on other allergens in children are needed. Patient, carer and practitioner education into AR and its treatment are a vital part of management.

Phenotypes and endotypes of rhinitis and their impact on management: a PRACTALL report

Rhinitis is an umbrella term that encompasses many different subtypes, several of which still elude complete characterization. The concept of phenotyping, being the definition of disease subtypes on the basis of clinical presentation, has been well established in the last decade. Classification of rhinitis entities on the basis of phenotypes has facilitated their characterization and has helped practicing clinicians to efficiently approach rhinitis patients. Recently, the concept of endotypes, that is, the definition of disease subtypes on the basis of underlying pathophysiology, has emerged. Phenotypes/endotypes are dynamic, overlapping, and may evolve into one another, thus rendering clear-cut definitions difficult. Nevertheless, a phenotype-/endotype-based classification approach could lead toward the application of stratified and personalized medicine in the rhinitis field. In this PRACTALL document, rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed. We emphasize the concept of control-based management, which transcends all rhinitis subtypes.

Local allergic nasal reactions convert to classic systemic allergic reactions: a long-term follow-up

BACKGROUND

There is poor knowledge about the evolution of the negative skin test in local allergy over time. Does the negative skin test of patients with local allergies remain negative permanently or does it become positive?

METHODS

We describe our long-term observation concerning the evolution of the negative skin test over time. This is a retrospective, follow-up study using data from the medical records of a group of patients with local allergy. A total of 42 patients aged between 3 and 70 years (median age: 31.5 years) were studied. The duration of follow-up varied from 1 to 27 years. Skin tests were performed using the skin-prick test and intracutaneous techniques for pollen, molds, mites, feathers (goose and duck) and animal danders. Nasal provocation tests were conducted with the same allergens. Additionally, specific IgE in 17 patients was measured by enzyme allergosorbent test.

RESULTS

During the period of observation, the negative skin test reactions converted into positive reactions in 17 patients (40%). In addition to the negative skin reactions, 55% of the patients also presented positive skin reactions. The conversion rate was higher in children and adolescents than in adults. In 4 patients, conversions occurred >7 years after the initial examination. Specific IgE was negative in all but 2 patients, in whom the conversion in the skin test was accompanied by a switch from negative to positive specific IgE.

CONCLUSION

Conversions from local to classic systemic respiratory allergic reactions appear to be a common phenomenon.

Rhinitis in the first 18 months of life: exploring the role of respiratory viruses

BACKGROUND

Rhinitis is common in early childhood, but allergic rhinitis is considered a later manifestation of the atopic march. This study aimed to evaluate rhinitis (allergic and non-allergic) in the first 18 months of life, its link with other atopic manifestations and the role of respiratory viruses.

METHODS

Subjects (n = 1237) of the Singapore GUSTO birth cohort were followed up quarterly until 18 months of age with questionnaires to screen for rhinitis symptoms lasting at least 2 wk and with monthly calls to positive subjects to detect prolonged/recurrent rhinitis symptoms (total duration ≥ 4 wk). Anterior nasal swabbing for molecular-based virus detection was conducted during these visits and near (within a month) rhinitis episodes. Skin prick testing to common environmental and food allergens was conducted at the 18 month visit.

RESULTS

Prolonged/recurrent rhinitis was significantly associated with history of parental atopy (mother: aOR = 2.17; father: aOR = 1.82) and atopic comorbidities of eczema (aOR = 2.53) and wheeze (aOR = 4.63) (p < 0.05), though not with allergen sensitization. Although the frequency of nasal respiratory virus detection during scheduled quarterly visits did not differ between prolonged/recurrent rhinitis and matched controls (p > 0.05), virus detection was higher in swabs obtained within a month following rhinitis episodes in prolonged/recurrent rhinitis subjects compared with scheduled visits (adjusted p = 0.04).

CONCLUSIONS

Based on the duration of rhinitis symptoms, this study defined a subset of early childhood rhinitis which was associated with atopic predisposition and comorbidities. Persistent respiratory viral shedding may contribute to the symptomatology. Whether this entity is a precursor of subsequent childhood allergic rhinitis will require longer follow-up.

Early childhood IgE reactivity to pathogenesis-related class 10 proteins predicts allergic rhinitis in adolescence

BACKGROUND

Component-resolved diagnosis might improve the prediction of future allergy in young children.

OBJECTIVE

We sought to investigate the association between IgE reactivity to the pathogenesis-related class 10 (PR-10) protein family and allergic rhinitis to birch pollen (ARbp) from early childhood up to age 16 years.

METHOD

Questionnaire data and sera obtained at 4, 8, and 16 years of age from the Barn/Children Allergi/Allergy Milieu Stockholm Epidemiologic (BAMSE) study birth cohort were used. Sera from 764 children were analyzed for IgE reactivity to 9 PR-10 allergen proteins at the 3 time points by using an allergen chip based on ISAC technology. ARbp was defined as upper airway symptoms during birch pollen exposure.

RESULTS

IgE reactivity to Bet v 1 was found in 12%, 17%, and 25% of children at 4, 8, and 16 years of age. IgE reactivity of PR-10 proteins showed a hierarchic intrarelationship: Bet v 1 > Mal d 1 > Cor a 1.04 > Ara h 8 > Pru p 1 > Aln g 1 > Api g 1 > Act d 8 > Gly m 4. There was an increased risk of incidence and persistence of ARbp up to age 16 years with increasing levels of Bet v 1-specific IgE or increasing numbers of IgE-reactive PR-10 proteins at 4 years. Children with severe ARbp at age 16 years had higher levels of Bet v 1-specific IgE at age 4 years compared with children with mild symptoms.

CONCLUSION

ARbp at age 16 years can be predicted by analysis of IgE reactivity to PR-10 proteins in early childhood.

Current recommendations and emerging options for the treatment of allergic rhinitis

Allergic rhinitis (AR) is one of the most common diseases and represents a global health problem, currently affecting up to 30% of the general population, with a continuously increasing prevalence and significant comorbidities and complications. The aim of this review is to provide an update on AR treatment, with a focus on current therapies defined by AR and its impact on asthma guidelines and with a particular emphasis on new and future therapeutic perspectives.

Measurement of Japanese cedar pollen-specific IgE in nasal secretions

BACKGROUND

Japanese cedar pollen (JCP) is the most common allergen for seasonal allergic rhinitis in Japan. Little is known about local production of immunoglobulin (Ig)E in people with or without Japanese cedar pollinosis. The aims of this study were to measure levels of JCP-specific IgE in nasal secretions and determine correlations with levels in serum.

METHODS

Forty-six subjects were enrolled in this study, comprising 24 symptomatic subjects, 9 asymptomatic subjects sensitized to JCP, and 13 subjects not sensitized to JCP. Nasal secretions were obtained during a period of Japanese cedar dispersal, and levels of JCP-specific IgE were measured with CAP-fluorescent enzyme immunoassay. Serum JCP-specific IgE and total IgE were also measured using the same method.

RESULTS

Among the 46 subjects enrolled, JCP-specific IgE in nasal secretions was measureable in 43 subjects. Irrespective of symptom development, sensitized subjects showed higher levels of JCP-specific IgE in nasal secretions than non-sensitized subjects. A significant moderate correlation was observed between JCP-specific IgE levels in nasal secretions and serum in all 43 subjects. With stratification by subject group, only symptomatic subjects showed a substantial correlation between JCP-specific IgE levels in nasal secretions and serum.

CONCLUSIONS

Our results imply a certain association between JCP-specific IgE in nasal secretions and sensitization of Japanese cedar pollinosis. Therefore, levels of allergen-specific IgE in nasal secretions can be used as an alternative diagnostic marker for allergic rhinitis patients.

Pediatric chronic rhinosinusitis

Pediatric chronic rhinosinusitis is a multifactorial inflammatory and infectious disorder. It likely reflects a dysfunction at the site of the interaction between host and environmental factors in the nose and sinuses. Our limited understanding of this common childhood disease makes it difficult to diagnose and to treat effectively. This review focuses on the scope of manifestations particular to the pediatric form of the disease, diagnostic challenges, and epidemiologic data. The normal development of sinuses in children, the role of inflammation, and biofilm and immune responses in the pathophysiology of chronic rhinosinusitis in pediatric patients are discussed. Predisposing and comorbid factors contributing to this disorder or associated with it are described. The current investigational and therapeutic approaches are presented, including recommendations for imaging and medical and surgical therapy. Various aspects of the disease that are still subject of controversy are underscored. Advice for what constitutes a reason to involve a multidisciplinary collaboration in the care of a child with chronic rhinosinusitis is provided.

Increased local IgE production induced by common aeroallergens and phenotypic alteration of mast cells in Chinese eosinophilic, but not non-eosinophilic, chronic rhinosinusitis with nasal polyps

BACKGROUND

Eosinophilic and non-eosinophilic chronic rhinosinusitis with nasal polyps (CRSwNP) display distinct patterns of inflammation. However, the pathogenic mechanisms underlying the heterogeneity of CRSwNP need further investigation.

OBJECTIVE

To investigate local immunoglobulin E (IgE) production and phenotype of mast cells in eosinophilic and non-eosinophilic CRSwNP in Chinese.

METHODS

Total and specific IgE levels were analysed by means of the ImmunoCAP system. The molecular steps involved in class-switch recombination to IgE were investigated using RT-PCR assays. Mast cell phenotypes, IgE- and high-affinity IgE receptor (FcεRI)-positive cells, and allergen binding to specific IgE in sinonasal mucosa were determined by means of immunohistochemistry.

RESULTS

Compared with controls and non-eosinophilic CRSwNP, local total IgE levels were increased, and local specific IgE to common aeroallergens was more frequently found, in Chinese eosinophilic CRSwNP independent of atopy and without significant association with Staphylococcus aureus enterotoxins. The ε germline gene transcript was also more frequently detected in eosinophilic CRSwNP. The number of IgE- and FcεRI-positive cells was increased in eosinophilic CRSwNP. Most IgE- and FcεRI-positive cells were mast cells. Dust mite antigens could bind to IgE on mast cells in situ. The number of mast cells positive for both tryptase and chymase and activated mast cells was increased in eosinophilic CRSwNP and the number of activated mast cells positively correlated with local IgE level, eotaxin-1 level, and eosinophil count in CRSwNP.

CONCLUSIONS AND CLINICAL RELEVANCE

The local IgE induced by common aeroallergens may mediate mast cell activation and contribute to subsequent eosinophilic inflammation in Chinese CRSwNP. This study offers a rationale for considering intervention strategies designed to target 'local allergy' in eosinophilic CRSwNP.

Nonspecific Hyper-reactivity and Localized Allergy

Objective

Disagreement between results of skin prick test (SPT) and nasal provocation tests (NPT) causes difficulty in differential diagnosis of allergic rhinitis (AR) and nonallergic rhinitis (NAR). We hypothesized this discrepancy could be due to the nonspecific hyper-reactivity (NHR) and localized allergy of the nasal cavity.

Study Design

Prospective pilot.

Setting

Academic tertiary rhinologic practice.

Subjects and Methods

Sixty patients with AR and 62 with NAR were enrolled. We categorized patients according to results of SPT and NPT. We compared: (1) the clinical characteristics and severity of the disease, (2) change of minimal cross-sectional area (MCA) and total nasal volume (TNV) after normal saline (NS) challenge, and (3) change of nasal symptoms and acoustic parameters after intranasal house dust mite (HDM) challenge between groups.

Results

Patients in groups A (SPT[+]/NPT[+]) and C (SPT[–]/NPT[+]) complained of more persistent discomfort than those in groups B (SPT[+]/NPT[–]) and D (SPT[–]/NPT[–]). The proportion of moderate to severe symptoms was significantly higher in groups A, B, and C compared to group D. After NS challenge, MCA/TNV showed a significantly greater decrease in groups A (MCA: 27.6% ± 21.3%, TNV: 24.6% ± 16.4%) and C (MCA: 31.2% ± 24.0%, TNV: 24.1% ± 23.4%) compared to groups B (MCA: 0.1% ± 13.2%, TNV: 3.9% ± 13.5%) and D (MCA: 2.1% ± 12.1%, TNV: 2.0% ± 17.2%) ( P < .05). After HDM challenge, groups A/B showed a greater decrease in MCA (Group A: 62.4% ± 16.1%, Group B: 6.4% ± 11.3%) compared to groups C/D (Group C: 45.5% ± 14.4%, Group D: –3.0% ± 9.5%).

Conclusion

NHR and/or localized allergy should be considered in patients with rhinitis whose SPT and NPT results are not in agreement.

[Local (exclusive) IgE production in the nasal mucosa. Evidence for local allergic rhinitis]

BACKGROUND

IgE production at the site of the nasal mucosa without systemic allergic sensitization in skin tests or in serum represents so-called "local allergic rhinitis (LAR)" as a subgroup of patients with symptoms of allergic rhinitis (AR). Formerly, in case of negative allergological test results, seasonal (intermittent) or perennial (persistent) allergic symptoms have been diagnosed as "non-allergic rhinitis" (NAR). However, there is evidence for specific Th2 cytokine, tryptase, and ECP (eosinophil catonic protein) production in the nasal secretion after allergen exposure in these patients without systemic sensitization.

DIAGNOSIS

Taking this into account, we recommend performing an allergen-specific nasal challenge and measuring the (local) nasal IgE-levels in addition to standard allergy tests in clinical routine in this subgroup of patients. These tests should be perfomed while or shortly after allergen exposure. In addition, an update of the allergy testing should be performed after a time interval since it has been demonstrated that patients formerly diagnosed with NAR may develop LAR or AR, or patients with LAR may develop AR in the future.

TREATMENT

The pharmacological therapeutic options in LAR are in line with the treatment of AR. If and to what extent this subgroup of AR patients benefit from allergen-specific immunotherapy (SIT) is currently being evaluated in clinical trials.

Serum eosinophil cationic protein level in Chinese subjects with nonallergic and local allergic rhinitis and its relation to the severity of disease

BACKGROUND

Nonallergic rhinitis (NAR) is a common disease, and local allergic rhinitis (LAR) is a newly described entity that is called "entopy" in recent years. However, the etiology and incidence of NAR and LAR are uncertain. This study evaluates the incidence of LAR in Chinese subjects and serum eosinophil cationic protein (ECP) levels in patients with NAR and LAR and its relationship with symptom scores.

METHODS

Positive skin-prick tests (SPT), nasal allergen provocation testing (NAPT) to Dermatophagoides farinae (DF), serum Phadiatop tests, and symptom score evaluations were performed in 147 patients with nonatopic persistent rhinitis. LAR was diagnosed by positive NAPT to DF results. The serum ECP level was measured using the UniCAP100 automated system by enzyme-linked immunosorbent assay (Pharmacia Diagnostics, Uppsala, Sweden).

RESULTS

Twelve patients were diagnosed with LAR, and 135 patients were diagnosed with NAR. There was no statistical difference of the visual analog scale scores between the two groups. Serum ECP was significantly increased in the patients with NAR. Serum ECP in the LAR group showed no difference compared with the NAR group or the controls. In the NAR group, nasal obstruction, rhinorrhea, and total scores had close and statistically significant relationships with serum ECP level.

CONCLUSION

The present study provides the first evidence that LAR exists in Chinese subjects. This study also suggests that eosinophils and ECP take part in the pathogenesis of NAR. A local examination for ECP and specific IgE in nasal lavage fluid or secretions in patients with LAR should be performed in a future study.

The development of allergic rhinitis in children previously diagnosed as nonallergic rhinitis

BACKGROUND

Nonallergic rhinitis (NAR) is characterized by nasal symptoms similar to allergic rhinitis (AR) without an IgE-mediated immune response. Limited data are available on the natural history of NAR in its progression toward AR, particularly in children. This study evaluates the development of AR in children who were previously diagnosed with NAR.

METHODS

Children with the diagnosis of NAR during the period of 2005-2007 were reevaluated in 2010. Nasal symptoms, disease severity, comorbidities, rescue medication scores (RMSs), and skin-prick test to aeroallergens were assessed.

RESULTS

We recruited 175 children with an early diagnosis of NAR. The median age was 5.7 years, 62.9% were boys and 45.7% had family history of atopy. At reevaluation, 41% of children with previously diagnosed NAR developed sensitization to aeroallergens and were reclassified as having AR. The most frequent aeroallergen sensitization was Dermatophagoides pteronyssinus (59.7%), followed by Dermatophagoides farinae (54.2%) and American cockroach (38.9%). Children who developed AR had more nasal/eye symptoms, higher severity, and RMSs than children who did not develop AR. The predictors of developing AR were persistent nasal symptoms (adjusted odds ratio [OR], 8.9; 95% CI, 3.2-24.6), nasal itching (adjusted OR, 3.4; 95% CI, 1.2-9.5), triggered by house dust (adjusted OR, 4.3; 95% CI, 1.6-11.9) and animal danders (adjusted OR, 15.8; 95% CI, 3.3-76.1), and family history of atopy (adjusted OR, 6.0; 95% CI, 2.3-15.9).

CONCLUSION

Children with NAR who had family history of atopy, persistent nasal symptoms, and symptoms triggered by aeroallergens should be reevaluated periodically for the development of AR. This study was part of the clinical trial NCT01068808 registered in www.clinicaltrials.gov.

Local atopy is more relevant than serum sIgE in reflecting allergy in childhood adenotonsillar hypertrophy

BACKGROUND

There was a lack of convincing evidence supporting the influence of allergy on the adenotonsillar hypertrophy (ATH). We investigated the presence of specific IgE (sIgE) in the serum and adenotonsillar tissues in children with ATH.

METHODS

A Pharmacia ImmunoCAP system was used to test sIgE against 31 allergens in the serum in 83 children with ATH before adenotonsillectomy. sIgE against 15 representative allergens were detected in adenotonsillar tissues from 20 of those children.

RESULTS

A total of 51 (61.45%) children had positive serum sIgE. 20 children with ATH had positive sIgE to more than two allergens at both tonsils and adenoids, although half of them were serum sIgE negative. The percentage of subjects with positive sIgE expression in adenoids and tonsils was 50.0% and 42.9%, respectively, among the subjects with positive serum sIgE expression. Of subjects with negative serum sIgE expression, local sIgE was detected in 36.0% of adenoids and 43.8% of tonsils, respectively. The rate of sIgE presence in local tissue (adenoids or tonsils) was significantly higher than that seen in the serum.

CONCLUSION

This study provided evidence that there was an important role for allergic inflammation in the ATH. The inconsistency in sIgE expression between adenotonsillar and serum suggests a role of local atopy in childhood ATH.

Seeking allergy when it hides: which are the best fitting tests?

In the common practice of respiratory allergy, the confirmation by IgE tests of the relationship between the occurrence and duration of symptoms and the exposure to specific inhalant allergens allows an aetiological diagnosis. However, to see patients with suggestive history but negative IgE tests is not rare, and this generally leads to a diagnosis of nonallergic rhinitis or asthma. In many cases, such diagnosis is wrong, because the patient may be revealed as allergic by using additional testing. This is true for local allergic rhinitis, characterized by an exclusive IgE production in the nasal mucosa, that may be correctly diagnosed by performing a nasal IgE measurement or a nasal provocation test with the suspected allergen (s). Another misleading issue is the role of T cell-mediated, delayed hypersensitivity in the pathophysiology of rhinitis and asthma. Recent studies showed that in patients with rhinitis or asthma and negative IgE tests, especially when there is a positive history for current or past atopic dermatitis, the clinical symptoms are actually driven by such mechanism, that may be detected by performing an atopy patch test (APT). The allergen source most frequently responsible for this kind of allergy is the house dust mite, but other allergens may also be involved. Thus, before delivering a diagnosis of nonallergic rhinitis or asthma in patients with negative result to common allergy testing, further tests are needed. To miss the diagnosis of allergy has obvious consequences in terms of management, including allergen avoidance, patient's education, and specific immunotherapy.

Dissecting the role of eosinophil cationic protein in upper airway disease

PURPOSE OF REVIEW

Eosinophil granulocyte myeloid cells are increased in atopic and nonatopic rhinitis, chronic rhinosinusitis (CRS) and atopic keratoconjunctivitis, diseases of the upper respiratory tract. Eosinophils contain several basic granule proteins, the best known being the eosinophil cationic protein (ECP). ECP is a cytotoxic, pro-fibrotic ribonuclease, which is found deposited in these eosinophil-related diseases and is often used in parallel with blood eosinophilia to monitor those diseases. The contribution of eosinophils and their granule proteins to disease pathogenesis have been debated; recent findings might bring these cells to the center of attention.

RECENT FINDINGS

Novel mediators of atopic disease, interleukin-17 (IL-17) and IL-33 have been found in the upper respiratory tract. These cytokines stimulate eosinophils to survival and degranulation, IL-17 via granulocyte-macrophage colony-stimulating factor (GM-CSF), and IL-33 directly. Transforming growth factor (TGF)-β has been found in CRS and atopic keratoconjunctivitis mucosa, its production possibly stimulated by ECP. ECP is detected in nasal mucosa of local allergic reactions, entopy, in rhinitis and CRS. ECP might be released from freely circulating eosinophil granules or in association with eosinophil mitochondrial DNA, both means of release for pathogen defence.

SUMMARY

Novel evidence suggests that eosinophils and ECP might have new prominent roles in development of diseases of the upper respiratory tract.

A role for measurement of nasal IgE antibodies in diagnosis of Alternaria-induced rhinitis in children

BACKGROUND

Rhinitis is a very common disease, frequently caused by sensitisation to inhalant allergens. Negative results from skin prick tests (SPT) and in vitro IgE tests generally lead to a diagnosis of non-allergic rhinitis. However, it is possible, as indicated by studies addressed with dust mites or pollens that the production of specific IgE occurs exclusively at nasal level.

METHODS

We measured specific nasal IgE in children suffering from rhinitis in the periods when Alternaria spores were present in the air. All subjects underwent SPT with a standard panel of aeroallergens (Stallergenes, Milan, Italy) and, in the same session, to nasal IgE test (NT). Nasal provocation test (NPT) with Alternaria was used as reference.

RESULTS

Fifty-six subjects were included in the study. Of them, 20 (37.5%) were positive to SPT and 45 (80.3%) were positive to NT. In particular, 11 subjects (19.6%) had a positive SPT and a negative NT; 36 (64.3%) had a negative SPT and a positive NT; and 9 (16.1%) were positive to both tests. Positivity of NT and NPT was observed in 36 patients (69.6%), while positivity of SPT and NPT was observed in 15 patients (26.8%). This difference was highly significant (p<0.0001).

CONCLUSIONS

These findings suggest that sensitisation to Alternaria is frequently expressed by exclusive production of specific IgE in the nasal mucosa. Thus, measuring nasal IgE in children with rhinitis and negative SPT during the period of presence of Alternaria spores seems helpful to avoid a mistaken diagnosis of non-allergic rhinitis.

Natural course and comorbidities of allergic and nonallergic rhinitis in children

BACKGROUND

Not much data are available from large, unselected, birth cohort studies on the natural course and comorbidities of rhinitis in children.

OBJECTIVE

To study phenotypes of rhinitis in relation to the natural course and comorbidities of allergic diseases in preschool-age and early school-age children.

METHODS

We analyzed data from a birth cohort of 2024 children, for whom information on IgEs against 8 common inhaled allergens was available, collected at age 4 and 8 years. The children were assigned to groups of allergic rhinitis (rhinitis with sensitization to allergens), nonallergic rhinitis (rhinitis without sensitization), allergic sensitization but no rhinitis, or neither rhinitis nor sensitization.

RESULTS

The proportion of children with allergic rhinitis increased from 5% to 14% from age 4 to 8 years, whereas the proportion of children with nonallergic rhinitis decreased slightly over the same period of development, from 8% to 6%. Of the children with allergic rhinitis when they were 4 years old, 12% underwent remission by the time they were 8 years old; of the children with nonallergic rhinitis, 73% underwent remission during this period of development. Among 4-year-olds without rhinitis who were sensitized to allergen, 56% had allergic rhinitis when they were 8 years old. Among 4- and 8-year-olds, allergic rhinitis and nonallergic rhinitis were associated with asthma, eczema, and food hypersensitivity. Twenty-five percent of 8-year-olds with allergic rhinitis also had oral allergy syndrome.

CONCLUSIONS

Fewer preschool-age children with allergic rhinitis undergo remission than do those with nonallergic rhinitis. Sensitization to inhaled allergens at an early age (4 years) precedes the development of allergic rhinitis, whereas symptoms of rhinitis do not. Oral allergy syndrome is common among 8-year-olds with allergic rhinitis.

Questionnaire predictors of atopy in a US population sample: findings from the National Health and Nutrition Examination Survey, 2005-2006

Allergic conditions and biochemical measures are both used to characterize atopy. To assess questionnaires' ability to predict biochemical measures of atopy, the authors used data on 5 allergic conditions (allergy, hay fever, eczema, rhinitis, and itchy rash) and serum-specific immunoglobulin E (IgE) levels from the 2005-2006 National Health and Nutrition Examination Survey. Atopy was defined as 1 or more positive specific IgEs (≥0.35 kU/L). Questionnaire responses were assessed for sensitivity, specificity, and positive and negative predictive values for atopy. In this population-based US sample, 44% of participants were specific IgE-positive and 53% reported at least 1 allergic condition. Discordance between atopy and allergic conditions was considerable; 37% of persons with atopy reported no allergic condition, and 48% of persons who reported an allergic condition were not atopic. Thus, no combination of self-reported allergic conditions achieved both high sensitivity and high specificity for IgE. The positive predictive value of reported allergic conditions for atopy ranged from 50% for eczema to 72% for hay fever, while the negative predictive value ranged from 57% for eczema to 65% for any condition. Given the high proportion of asymptomatic participants who were specific IgE-positive and persons who reported allergic conditions but were specific IgE-negative, it is unlikely that questionnaires will ever capture the same participants as those found to be atopic by biochemical measures.

The impact of age on prevalence of positive skin prick tests and specific IgE tests

Aging is associated with modifications of the immune system, defined as immunosenescence. This could contribute to a reduced prevalence of allergic disease in the elderly population. In this regard, atopy has rarely been considered in the clinical assessment of the geriatric respiratory patient. This article is a review of the available literature assessing the impact of age on atopy. In the majority of papers, we found a lower prevalence of atopy in the most advanced ages, both in healthy subjects and in individuals affected by allergic respiratory diseases. Unfortunately, no large, longitudinal studies performed in the general population have been conducted to further explore this observation. Although available data seem to favor the decline of allergen sensitization with age, the prevalence of allergic sensitizations in the elderly population with respiratory symptoms is substantial enough to warrant evaluation of the atopic condition. From a clinical perspective, allergic reactions in older adults can have the same or even worse manifestations compared to young people. For this reasons, the evaluation of the atopic condition also in the geriatric patient is recommended. Thus, the role of atopy as it pertains to the diagnosis, therapy (adoption of preventive measure such as removal of environmental allergen or immunotherapy), and prognosis (influence on morbidity and mortality) of chronic respiratory illnesses in the elderly is addressed.