Minimal persistent inflammation is present at mucosal level in patients with asymptomatic rhinitis and mite allergy

Impact of allergic rhinitis on asthma: effects on spirometric parameters

BACKGROUND

Close association exists between allergic rhinitis and asthma. Moreover, allergic rhinitis is a strong risk factor for the onset of asthma in adults. This study was aimed at evaluating a large group of patients with moderate-to-severe and persistent allergic rhinitis alone for investigating the presence of spirometric abnormalities and possible risk factors related to it.

METHODS

A total of 392 patients with persistent allergic rhinitis were prospectively and consecutively evaluated. Clinical examination, skin prick test and spirometry were performed in all patients.

RESULTS

There were 24 (6.1%) patients with forced vital capacity (FVC < 80%) of predicted, 50 (12.8%) with forced expiratory volume in the first second (FEV(1) < 80%) of predicted and 341 (87.0%) with forced expiratory flow at 25% and 75% of the pulmonary volume (FEF(25-75)) < 80% of predicted. The logistic regression analysis evidenced that rhinitis duration (OR(Adj): 1.9/year) and sensitization to house dust mites (OR(Adj): 8.2) were significantly associated with impaired values of 2 or 3 spirometric parameters.

CONCLUSION

This study highlights the close link between upper and lower airways and the role of some risk factors, such as duration and mites sensitization, as early prognostic markers of bronchial involvement in patients with moderate-to-severe and persistent allergic rhinitis alone.

Allergic rhinitis and asthma comorbidity: ARIA classification of rhinitis does not correlate with the prevalence of asthma

BACKGROUND

Allergic rhinitis and asthma comorbidity is supported by both the similar underlying pathogenesis and immunologic mechanisms. The aim of this study was to verify whether the characteristics of rhinitis classified according to the new Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines correlate with the prevalence of asthma.

METHODS

From 1 March to 30 June 2002, a multi-centre cross-sectional study was conducted by 154 allergists chosen from throughout Italy. Duration, severity of rhinitis (according to the ARIA classification) and the type of allergic sensitizations were compared with the prevalence of asthma.

RESULTS

One thousand three hundred and twenty-one consecutive rhinitis-allergic patients aged 18 years or older were enrolled for the study. The majority of patients, 1060 (80.24%), were on medication at the time of their specialist visit. Mild intermittent rhinitis was diagnosed in 7.7% of patients, moderate/severe intermittent in 17.1%, mild persistent in 11.6%, and moderate/severe persistent in 63.6%. The prevalence of asthma was 48% in patients with mild intermittent rhinitis, 49.6% in moderate-severe intermittent rhinitis, 36.6% in mild persistent rhinitis and 47.5% in moderate severe persistent patients. No correlation between the ARIA categories of rhinitis and the prevalence of asthma was found. A multivariate analysis, after adjustment for age, sex, type of sensitization, level of severity and duration of rhinitis classified according to the ARIA guidelines, demonstrated that age, over 41 years [risk ratio (RR) 1.260, 95% confidence interval (CI) 1.072-1.482] and especially over 51 years (RR 1.460, 95% CI 1.237-1.723), sensitization to indoor allergens (mite and cat), (RR 1.203, 95% CI 1.060-1.366), and polysensitization (RR 1.178, 95% CI 1.004-1.383) are significant risk factors for asthma.

CONCLUSION

In allergic rhinitis (AR) patients referred to a specialist, the features of AR as defined by the ARIA classification are not able to predict the presence of asthma, therefore all such patients should be assessed for asthma.

Allergic patients have more numerous and prolonged respiratory infections than nonallergic subjects

BACKGROUND

Allergic disorders are characterized by type 2 helper T cell (Th2)-polarization, thus physiological type 1 helper T cell (Th1)-dependent mechanisms involved in fighting respiratory infections (RI) may be defective. It has previously been reported that allergic children have more numerous and severe RI than nonallergic ones.

OBJECTIVE

The aim of the study was to evaluate the number and duration of RI in adult allergic and nonallergic subjects.

METHODS

Six hundred and twenty-four subjects were studied; 202 of them were allergic (i.e. suffering from allergic rhinitis). The number of RI as well as the duration of the disease were recorded for 2 years.

RESULTS

Allergic subjects showed a significantly higher rate of RI episodes [adjusted incidence rate ratio (IRR) = 2.16, 95% confidence interval (CI) 1.94-2.41, P < 0.001] than subjects without allergy. The number of mild RI episodes was slightly higher in allergic subjects (IRR = 1.68, 95% CI 1.50-1.89, P < 0.001), while the number of severe episodes was markedly higher (IRR = 15.71, 95% CI 10.35-23.84, P < 0.001) when compared with nonallergic subjects. Moreover, allergic patients showed a longer total duration of RI than nonallergic subjects, with a mean difference of 17.4 days (95% CI 15.5-19.4, P < 0.001).

CONCLUSIONS

This study provides evidence that adult allergic patients have more numerous and prolonged RI than nonallergic subjects.

The effect of H1 antagonists carebastine and olopatadine on histamine induced expression of CC chemokines in cultured human nasal epithelial cells

BACKGROUND

CC chemokines have been shown to play an important role in inducing selective recruitment of inflammatory cells into local allergic inflammatory sites. CC chemokines are also known as histamine releasing factors. We previously showed that histamine enhances transcription of CC chemokines from nasal mucosa which leads to further induction of histamine release. This cyclic cascade may cause prolonged allergic inflammation. The aim of this study is to clarify the relationship between histamine and CC chemokine production by using human nasal epithelial cells (HNECs) and to examine the potential of H1 receptor (H1R) antagonists in new therapeutic approaches for the treatment of nasal allergy.

METHODS

HNECs were isolated from the nasal turbinates of patients diagnosed with nasal allergy. HNEC monolayers were cultured for 48 hours with or without histamine (10(-3) to 10(-5) mol/L). Furthermore, an H1R antagonist, either carebastine or olopatadine, was added to the supernatant (10(-3) to 10(-7) mol/L) 30 minutes before incubation with histamine. The expression of Regulated on Activation, Normal T-cell Expressed and Secreted (RANTES) and monocyte chemotactic protein-1 (MCP-1) in the culture media were measured by ELISA.

RESULTS

The release of RANTES and MCP-1 was significantly upregulated by histamine compared with the control group. Both carebastine and olopatadine inhibited the release of CC chemokine production to the control level in both groups.

CONCLUSIONS

This study suggests that the interaction between histamine and CC chemokines may prolong allergic inflammation in human nasal mucosa. We also demonstrate the potential use of H1R antagonists in new therapeutic approaches to the treatment of nasal allergy through inhibiting this histamine-CC chemokine interaction.

Nonspecific provocation of target organs in allergic diseases: EAACI-GA(2)LEN consensus report

It is widely accepted that nonspecific tissue reactivity is a distinct pathophysiological hallmark of allergic diseases, influenced by genetic and environmental factors different from those involved in causing sensitization and allergen response of target organs. This consensus document aims at reviewing procedures currently used for nonspecific provocation of the bronchi, nose and eye and for measuring their responsiveness to nonspecific stimuli.

Cellular adhesion molecules in chronic urticaria: modulation of serum levels occurs during levocetirizine treatment

BACKGROUND

Some antihistamines are capable of reducing levels of adhesion molecules in wealing tissues of patients with chronic urticaria (CU).

OBJECTIVES

To determine if 6 weeks of therapy with levocetirizine 5 mg once daily would also induce any decrease in serum levels of intercellular adhesion molecule-1, vascular cell adhesion molecule-1, endothelial leucocyte adhesion molecule-1 (ELAM-1) or P-selectin in subjects with CU and chronic autoimmune urticaria.

METHODS

Thirty-six patients with CU (18 with positive and 18 with negative autologous serum skin test) were studied, together with 10 control healthy subjects. All patients received levocetirizine 5 mg daily. Serum soluble cellular adhesion molecule (CAM) levels were determined by immunoenzymatic assay before and after the end of the study period. Disease activity was recorded according to the EAACI/GA(2)LEN/EDF scoring system.

RESULTS

After levocetirizine therapy CAM levels decreased in patients with CU, significantly in the cases of ELAM-1 and P-selectin. Patients' clinical scores improved during regular antihistamine therapy.

CONCLUSIONS

Levocetirizine 5 mg daily demonstrated a broad anti-inflammatory effect in patients with CU. The significant decrease in serum levels of ELAM-1 and P-selectin might reflect the inhibitory activity on neutrophil rolling and extravasation towards inflamed skin.

Allergic Subjects Have More Numerous Respiratory Infections and Severe Gastrointestinal Infections Than Non-Allergic Subjects: Preliminary Results

Allergic disorders are characterized by Th2-polarization, thus physiological Th1-dependent mechanisms for fighting infectious diseases (ID) may be defective. This study aims at evaluating the number and duration of respiratory (RI) and gastrointestinal diseases (GI) in allergic and non-allergic subjects in a particular community: the crew of an operative warship consisting of 189 persons (171 males and 18 females). The study period lasted for 5 months during an operative mission. The number and duration (days) of RI and GI were evaluated. Allergic subjects experienced more numerous RI (p=0.0029) and more severe GI (p=0.0001) than non-allergic subjects. This preliminary study provides evidence that allergic subjects may have more numerous RI and prolonged GI than non-allergic subjects.

Novel therapeutic interventions for allergic rhinitis

Allergic rhinitis is a high-prevalence disease, affecting 10 - 20% of the general population. Allergic rhinitis is sustained by an IgE-mediated reaction and by a complex inflammatory network of cells, mediators and cytokines that becomes chronic when exposure to allergen persists. A T(H)2-biased immune response is the background of the allergic inflammation. The current therapeutic strategy is mainly based on drugs (antihistamines, nasal corticosteroids, cromones and decongestants) and allergen immunotherapy. Drugs are (overall) effective in controlling symptoms but do not modify the immune background that leads to allergic inflammation and safety concerns may be present, especially for prolonged treatments. Immunotherapy can modify the allergic response but there is still room for improvement. Nowadays, several approaches are under investigation to optimise the management of allergic rhinitis. On one hand, new drugs and antimediators are being developed. On the other hand, attempts are being made to selectively block relevant signal pathways of allergic reaction. Finally, one of the major goals is to modify the T(H)2-biased immune response by improving the characteristics and modes of action of allergen immunotherapy.

Prevalence of allergic rhinitis and nasal smear eosinophilia in 11- to 15 yr-old children in Shiraz

Allergic rhinitis (AR) is a common condition among schoolchildren. The prevalence rate of AR differs among countries and even among regions within the same country. The objective of this study was to determine the prevalence of nasal symptoms and signs of AR and nasal smear eosinophilia in 11- to 15-yr-old children in Shiraz. A total of 4584 children aged 11-15 yr of both sexes were surveyed from May 1995 to April 1996, and nasal symptoms and signs of AR (sneezing, rhinorrhea, nasal blockage, itching, color change, mucosal swelling, nasal wetness, and nasal crease), based on questionnaire and ear, nose and throat (ENT) examination were recorded. In addition, smears were taken from nasal secretions and stained. The results compared with nasal smears related to 340 healthy children. 1008 (22%) schoolchildren had nasal symptoms of AR (based on the questionnaire), 445 (9.7%) were identified as having nasal symptoms and signs of AR (based on the questionnaire and ENT specialist examination), and 226 (5.8%) had nasal symptoms and signs of AR associated with nasal eosinophilia (based on the questionnaire, ENT specialist examination and positive nasal smear for eosinophilia). Nasal eosinophilia was present in 274 (62%) children with nasal symptoms and signs of AR. This survey showed that prevalence of nasal symptoms and signs of AR was high in schoolchildren in Shiraz. Nasal smear eosinophilia had a diagnostic specificity of 96% and sensitivity of 62% and seems to be a potentially valuable test for AR.

Treating asthma as an inflammatory disease

Asthma is a chronic inflammatory disease involving many different cell types and cellular elements. Evidence suggests that, in the long term, this inflammation leads to remodeling of the airways, airflow obstruction, and the bronchial hyperreactivity symptoms of asthma, and is present even in patients with intermittent disease. Patients with allergic asthma and those with seasonal allergic rhinitis are believed to have minimal persistent inflammation, and the two diseases often occur together. Early intervention with inhaled corticosteroids (ICS) is believed to modify the disease process and may limit long-term remodeling. ICS remain the cornerstone and "gold standard" of treatment for asthma.

Allergic children have more numerous and severe respiratory infections than non-allergic children

Allergic disorders are characterized by Th2-polarization, and hence physiological Th1-dependent mechanisms for fighting respiratory infections (RI) may be defective. This study aimed at evaluating the number and duration of RI in allergic and non-allergic children suffering from recurrent RI. One hundred seventeen children (4.02 +/- 1.0 yr, 72 males and 45 females) were studied during the spring, 46 were allergic. Allergic children showed a significantly higher number (mean 1.26 +/- 0.73) and longer duration of RI (8.92 days) in comparison with non-allergic group (0.94 +/- 1.37 and 4.85 days) (p = 0.0001 and p = 0.009, respectively). In conclusion, this study provides the evidence that allergic children have more numerous and severe RI than non-allergic children.

Acoustic rhinometry in nasal provocation test in perennial allergic rhinitis

Acoustic rhinometry is one method to evaluate nasal geometry by an acoustic reflection technique. The aim of this study was to investigate the changes in acoustic rhinometry after nasal provocation in patients with exclusively perennial allergic rhinitis. In 19 patients, acoustic rhinometry and active anterior rhinomanometry were performed before and after nasal provocation test. There was a statistically significant nasal flow reduction measured by active anterior rhinomanometry after nasal provocation (p < 0.05) and a median symptom score of four points, both indicating a positive response to nasal provocation. On the other hand, there was no statistically significant change in the values of acoustic rhinometry after nasal provocation (p > 0.05). In patients with exclusively perennial allergic rhinitis, acoustic rhinometry does not seem to significantly change after nasal provocation. In contrast, active anterior rhinomanometry values decreased significantly after nasal provocation. The presented results indicate that acoustic rhinometry does not seem to be a diagnostic method superior to active anterior rhinomanometry in this context.

Increased expression of lipoxygenase enzymes during pollen season in nasal biopsies of pollen-allergic patients

BACKGROUND

Exposure of patients sensitized to pollen triggers development of seasonal allergic rhinitis symptoms (SAR). Eicosanoids are a group of arachidonic acid metabolites contributing to the symptoms of SAR. The aim of this study was to investigate seasonal changes in the expression of enzymes of the eicosanoid pathway in the nasal mucosa of patients with SAR.

METHODS

Twenty SAR patients allergic to birch or grass and eight healthy subjects were included in the study. Patients registered rhinoconjunctivitis symptoms and use of rescue medication before and during the pollen season. Nasal biopsies were obtained before and around the peak of the season, sectioned and stained using markers for eosinophils, mast cells, T cells and neutrophils. Antibodies against the following enzymes were also used: cyclo-oxygenase (COX-1, COX-2), 5-lipoxygenase (5-LO), 5-lipoxygenase-activating factor (FLAP), LTA4 hydrolase (LTA4h) and LTC4 synthase (LTC4s).

RESULTS

During the pollen season symptoms of rhinoconjunctivitis and medication score increased significantly (P=0.001; P=0.001 respectively). During the pollen season numbers of eosinophils (P=0.02) and cell positive 5-LO (P=0.02), LTC4s (P=0.04) and LTA4h (P=0.02) increased significantly. During season number of mast cells and cells expressing 5-LO and LTA4h were higher in SAR than in healthy controls group (P=0.02; P=0.01; P=0.03 respectively).

CONCLUSION

In sensitized patients exposure to pollen allergen results in increased expression of enzymes of the eicosanoid pathway.

Persistent erythema and edema of the midthird and upper aspect of the face (morbus morbihan): evidence of hidden immunologic contact urticaria and impaired lymphatic drainage

BACKGROUND

A persistent erythema and edema of the midthird and upper aspect of the face, which bears some resemblance to Melkersson-Rosenthal syndrome and rosaceous lymphedema, has been characterized as morbus morbihan (MM) by French dermatologists. The disease of yet unknown cause starts with recurrent facial edema of short duration, which ultimately leads to persistent swelling after a period of weeks or months.

METHODS

We recruited 6 patients with MM and acquired their history, routine blood tests, and individual UV light tolerability. To check for contact allergies the allergen patch test and the open epicutaneous patch test were performed. To objectify the skin conditions laser Doppler flowmetry and 20-MHz ultrasound were used. Five patients with similar symptoms, but with definitely transient facial erythema and edema caused by proven contact urticaria on cosmetics served as a comparison group.

RESULTS

In all patients, routine blood tests and UVA/UVB light tests showed no pathologic results. Observations of 6 patients with MM revealed the common feature of a clinically relevant immunologic contact urticaria caused by various cosmetic ingredients, which could be diagnosed in all of them. Delayed resorption of the acute edema and prolonged inflammation were shown by laser Doppler flowmetry and 20-MHz ultrasound in the affected skin areas in patients with MM after induction of immunologic contact urticaria by a cosmetic ingredient. Strict avoidance of cosmetics yielded a remarkable clinical benefit in the follow-up examinations.

CONCLUSIONS

We conclude that recurrent and possibly subclinical inflammation caused by immunologic contact urticaria in conjunction with a locally pre-existing lowered lymphatic drainage plays a crucial role in the evolution of MM.

Role of FEF25%-75% as a predictor of bronchial hyperreactivity in allergic patients

BACKGROUND

The small airways may play an important role in the clinical manifestations of asthma. Forced expiratory flow between 25% and 75% (FEF25%-75%) has been proposed as an approximate measure of the caliber of distal airways. Bronchial hyperreactivity (BHR) is a feature of asthma.

OBJECTIVE

To evaluate the possible role of FEF25%-75% as a predictor of BHR in allergic patients with asthma and rhinitis.

METHODS

A total of 726 patients (mean +/- SD age, 24.7 +/- 6.3 years) were evaluated. Spirometry and methacholine bronchial challenge were evaluated in all the participants.

RESULTS

A difference between forced expiratory volume in 1 second and FEF25%-75% greater than 20 or a ratio between these variables greater than 1.24 discriminates between patients with no response to a mild response to methacholine vs patients with a moderate-to-severe response with high sensitivity (P < .001).

CONCLUSION

This study highlights the possible role of FEF25%-75% in predicting BHR in allergic individuals with airway disorders.

Capsaicin for allergic rhinitis in adults

BACKGROUND

Allergic rhinitis represents a global health problem. Non-specific nasal hyperresponsiveness is an important feature of allergic and non-allergic rhinitis. This phenomenon is believed to result from the effect of allergic inflammation on the sensory nerves that supply the upper airway mucosa. A pharmacologic agent that has proved useful in the investigation of effects of neuronal stimulation is capsaicin, the pungent component of hot pepper. Intranasal capsaicin specifically stimulates afferent nerves consisting mostly of unmyelinated C fibers and some myelinated A-delta fibers. As a result it can trigger central and axonal reflexes, the latter being putatively mediated by the release of neuropeptides. Capsaicin as a blocking agent of neuropeptides, blocks the axon reflex and may exert a curative effect on allergic rhinitis.

OBJECTIVES

To assess the effectiveness of capsaicin for allergic rhinitis in adults.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to 2006) and EMBASE (1974 to 2006). We assessed bibliographies from included studies, and contacted authors of known studies for additional information about published and unpublished trials. The date of the most recent search was January 2006.

SELECTION CRITERIA

Randomised controlled trials of capsaicin for allergic rhinitis in adults were included.

DATA COLLECTION AND ANALYSIS

Three reviewers read each paper, blind to its identity. Decisions concerning inclusion were made by simple majority. We all performed quality assessment independently.

MAIN RESULTS

One small trial did not find evidence that intranasal capsaicin had a therapeutic effect in allergic rhinitis. A small pharmacological effect on clinical histamine dose response was found. After treatment, leukotriene levels in nasal lavage did not increase in the capsaicin group.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the use of capsaicin in clinical practice.

Emerging anti-inflammatory agents for allergic rhinitis

Allergic rhinitis (AR) is a high-prevalence disease, affecting 10-15% of the general population. AR is sustained by an IgE-mediated reaction, and by a complex inflammatory network of cells, mediators and cytokines that becomes chronic when exposure to allergen persists. A T helper 2 (TH2)-biased immune response is the basis for the allergic inflammation. The current therapeutic strategy is mainly based on drugs (antihistamines, nasal corticosteroids, cromones, decongestants) and allergen immunotherapy. Drugs are overall effective in controlling symptoms, but do not modify the immune background that leads to allergic inflammation, and safety concerns may be present especially for prolonged treatments. Immunotherapy can modify the allergic response, but there is still space for improvement. Nowadays, several approaches are under investigation to optimise the management of AR. On one hand, new drugs and antimediators are being developed; on the other hand, attempts are made to selectively block relevant signal pathways of allergic reaction. Finally, one of the major goals is to modify the TH2-biased immune response by improving the characteristics and modes of action of allergen immunotherapy.

Three-year follow-up of clinical and inflammation parameters in children monosensitized to mites undergoing sub-lingual immunotherapy

Parallel follow-up of clinical and inflammatory markers during sub-lingual immunotherapy (SLIT) is highly beneficial. Twenty-four children (age 4-16) monosensitized to house dust mite were randomized to receive either active or placebo SLIT for 1 yr in a double-blind placebo controlled design (Marcucci et al., Allergy 2003: 58: 657-62). Thereafter, for 2 yr they all received active treatment. Symptom scores for rhinitis, asthma, and drug usage were daily recorded. Eosinophil cationic protein (ECP) and tryptase in sputum and nasal secretions, serum and nasal mite-specific immunoglobulin E (IgE) were recorded before treatment and at 10-12 months intervals. Nasal ECP and nasal tryptase after specific nasal provocation tests were significantly reduced as compared to baseline values (p = 0.0043 and 0.0195, respectively) in the third year of active treatment. None of the other inflammatory parameters was increased. In placebo treated patients all these parameters tended to decrease only after switching to active treatment. Clinical scores did not improve in treated vs. placebo patients in the double-blind placebo-controlled phase of the study. In both cohorts a clinical benefit was observed as intra-group score reduction as compared to baseline. A significant difference was reached in patients treated for 2 yr for rhinitis and asthma (p = 0.0009 and 0.0019, respectively) but not for drug usage and in patients treated for 3 yr for rhinitis, asthma, and drug usage (p = 0.0105, 0.0048, and 0.02, respectively). SLIT in children monosensitized to mites reverted the spontaneous increase in nasal IgE and in local parameters of allergic inflammation. These outcomes were followed by a consolidated clinical improvement in the second and third year of treatment.

Seasonal and perennial allergic rhinitis: is this classification adherent to real life?

BACKGROUND

Allergic rhinitis is traditionally subdivided into seasonal (SAR) and perennial (PAR), although the new definitions of persistent and intermittent were recently proposed. We assessed the validity of the traditional classification in a large group of subjects suffering from allergic rhinitis alone.

METHODS

Young males referred to a Navy Military Hospital for routine fitness visit, and reporting symptoms of rhinitis alone were selected. According to the sensitization they were subdivided into (i) sensitized to pollens only (seasonal, SAR), (ii) to perennial allergens only (perennial, PAR) and (iii) to both (mixed, MAR). Spirometry, methacholine challenge, severity and characteristics of symptoms were assessed in all participants.

RESULTS

Of 19 325 subjects, 2347 had allergic rhinitis. Seventy-two percent of the subjects had MAR, 17% SAR and 11% PAR. Ocular involvement and irritative symptoms were more frequent in SAR (P < 0.03), whereas obstruction was predominant in PAR (P < 0.01). Nasal symptoms varied according to the period of the year in SAR (P < 0.01) and PAR (P < 0.03). An overt bronchial obstruction was detected in 12% of PAR patients, in 7.8% of MAR, and in 4.2% of SAR. forced expiratory volume/1 s was significantly lower during season in SAR patients only (P < 0.05). The FEF25-75 was impaired in 22.5% MAR patients, 21% PAR, and 14% SAR, with a seasonal change in SAR (P < 0.05) and PAR (P < 0.001). Bronchial hyperreactivity was present in 82.2% of PAR, 73.6% of MAR, and 53.5% of SAR, with a seasonal change in SAR (P < 0.001) and MAR (P < 0.05).

CONCLUSIONS

This study provides evidence that up to 80% of allergic rhinitics have a mixed form, and SAR and PAR definitions are poorly adherent to real life. Lung involvement is frequent in patients reporting nose symptoms alone.

Characteristics of intermittent and persistent allergic rhinitis: DREAMS study group

BACKGROUND

In the Allergic Rhinitis and its Impact on Asthma (ARIA) classification, intermittent and persistent rhinitis were proposed to replace seasonal and perennial allergic rhinitis (AR).

AIM

To better understand the ARIA classification of rhinitis.

METHODS

A cross-sectional study was carried out in 591 patients consulting ENT or allergy specialists for AR and 502 control subjects. The diagnosis of AR was based on a score for allergic rhinitis (SFAR) > or =7. Patients were classified according to the four ARIA classes (mild intermittent, mild persistent, moderate/severe intermittent and moderate/severe persistent). Allergen sensitization (skin prick tests (SPTs) or specific IgE) and co-morbidities were examined according to the ARIA classes.

RESULTS

Ten percent of patients had mild intermittent rhinitis, 14% mild persistent rhinitis, 17% moderate/severe intermittent rhinitis and 59% moderate/severe persistent rhinitis. Most patients with intermittent rhinitis had a pollen sensitivity, but 5% had a single house dust mite (HDM) sensitization. Over 50% of patients with persistent rhinitis were allergic to pollens or HDM. Asthma was present in 24% of rhinitis patients and in only 2% of the control population (P<0.0001). Patients with moderate/severe persistent rhinitis had the highest asthma prevalence (33%).

DISCUSSION

Intermittent and persistent rhinitis are not synonymous of seasonal and perennial rhinitis. Most patients consulting specialists have severe rhinitis. Asthma prevalence increases with duration and severity of rhinitis supporting the ARIA major recommendation that patients with persistent rhinitis should be evaluated for asthma.

Quality of life and polysensitization in young men with intermittent asthma

BACKGROUND

Health-related quality of life (HRQoL) represents an important variable in asthma management. To date, to our knowledge, no study has explored the relationship between HRQoL and sensitization in patients with asthma.

OBJECTIVE

To evaluate the relationships among HRQoL and sensitization, pulmonary function, and bronchial hyperreactivity in a group of young men with intermittent asthma.

METHODS

We studied 185 conscripts with intermittent asthma and bronchial hyperreactivity. The Asthma Quality of Life Questionnaire was used. Skin prick testing, spirometry, and methacholine challenge were performed in all participants.

RESULTS

The Asthma Quality of Life Questionnaire median scores were greater than 4, indicating suboptimal HRQoL. Polysensitization was significantly associated with the worst HRQoL, whereas pulmonary function and bronchial hyperreactivity category were not.

CONCLUSIONS

This study provides the first evidence that HRQoL is associated with polysensitization in intermittent asthma and underlines the importance of evaluating this issue when managing young patients with slight respiratory symptoms.

Psychologische Aspekte der Allergischen Rhinitis

Zusammenfassung. Theoretischer Hintergrund und Fragestellung: Die allergische Rhinitis ist die häufigste atopische Erkrankung, ihre Prävalenz scheint stetig zuzunehmen. Wie bei anderen chronischen Erkrankungen ist ein Einfluss psychischer Faktoren auf das Krankheitsgeschehen wahrscheinlich. Methode: Die vorliegende Übersichtsarbeit stellt Befunde aus 70 Jahren Forschung zur Psychologie der allergischen Rhinitis zusammen. Diese werden in ein Gliederungsraster integriert, das die Einordnung biopsychosozialer Bedingungsfaktoren erlaubt und die Manifestation auf verschiedenen Verhaltens- und Erlebensebenen berücksichtigt. Ergebnisse und Schlussfolgerungen: Krankheitsverhalten, Laienstörungskonzepte, Neurotizismus und psychophysiologische Stressreaktivität stellen psychologische Aspekte dar, die zur Chronizität der Erkrankung und zur subjektiven Beeinträchtigung beitragen. Es besteht in diesem Bereich noch erheblicher Forschungsbedarf.

Categorization of patients with allergic rhinitis: a comparative profile of "sneezers and runners" and "blockers"

BACKGROUND

The recent Allergic Rhinitis and Its Impact on Asthma (ARIA) workshop report classified patients into "sneezers and runners" and "blockers" and described a new disease severity categorization.

OBJECTIVE

To sketch the profile of these 2 groups and to evaluate the relevance of categorization.

METHODS

Patients were categorized as "sneezers and runners" (group 1) or "blockers" (group 2). The patients responded to a questionnaire that sought information on symptoms and associated factors. They were then categorized into seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR) groups and "intermittent" and "persistent" disease groups and compared.

RESULTS

A total of 114 patients (72 in group 1 and 42 in group 2) participated in the study. The significant features in group 1 were age at onset younger than 20 years (90%); birth date between June and September (61%); family history of atopy (88%); itching of skin (26%), eye (43%), ears (43%), and throat and palate (67%); and aggravation with dust (93%). History of breathlessness (90%), mouth breathing (81%), loss of smell (36%), and prior nasal surgery (31%) were significant in group 2. Significantly more patients in group 1 had SAR (54%) and moderate-severe intermittent disease (60%), whereas group 2 had PAR (81%) and mild persistent (69%) disease (P = .03). Patients classified as having SAR had intermittent disease (40, 83%) (P = .005), and those with PAR had persistent disease (51, 76%) (P < .001). Sixteen patients (24%) classified as having PAR were in the intermittent category, whereas 7 (17%) classified as having SAR were in the persistent category.

CONCLUSIONS

This study demonstrated that the 2 groups had distinct clinical profiles and that it is important to categorize patients, according to the ARIA report, into intermittent and persistent allergic rhinitis groups.

Cytokine dysregulation, inflammation and well-being

Cytokines mediate and control immune and inflammatory responses. Complex interactions exist between cytokines, inflammation and the adaptive responses in maintaining homeostasis, health, and well-being. Like the stress response, the inflammatory reaction is crucial for survival and is meant to be tailored to the stimulus and time. A full-fledged systemic inflammatory reaction results in stimulation of four major programs: the acute-phase reaction, the sickness syndrome, the pain program, and the stress response, mediated by the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Common human diseases such as atopy/allergy, autoimmunity, chronic infections and sepsis are characterized by a dysregulation of the pro- versus anti-inflammatory and T helper (Th)1 versus Th2 cytokine balance. Recent evidence also indicates the involvement of pro-inflammatory cytokines in the pathogenesis of atherosclerosis and major depression, and conditions such as visceral-type obesity, metabolic syndrome and sleep disturbances. During inflammation, the activation of the stress system, through induction of a Th2 shift, protects the organism from systemic 'overshooting' with Th1/pro-inflammatory cytokines. Under certain conditions, however, stress hormones may actually facilitate inflammation through induction of interleukin (IL)-1, IL-6, IL-8, IL-18, tumor necrosis factor-alpha and C-reactive protein production and through activation of the corticotropin-releasing hormone/substance P-histamine axis. Thus, a dysfunctional neuroendocrine-immune interface associated with abnormalities of the 'systemic anti-inflammatory feedback' and/or 'hyperactivity' of the local pro-inflammatory factors may play a role in the pathogenesis of atopic/allergic and autoimmune diseases, obesity, depression, and atherosclerosis. These abnormalities and the failure of the adaptive systems to resolve inflammation affect the well-being of the individual, including behavioral parameters, quality of life and sleep, as well as indices of metabolic and cardiovascular health. These hypotheses require further investigation, but the answers should provide critical insights into mechanisms underlying a variety of common human immune-related diseases.

Nasal conditioning in perennial allergic rhinitis after nasal allergen challenge

BACKGROUND

Antigen challenge in seasonal allergic rhinitis is considered to be associated with an increased ability of the nose to condition inspired air. In contrast, little is known about air conditioning after antigen challenge in perennial allergic rhinitis (PAR).

OBJECTIVE

The aims of this study were to investigate whether antigen challenge in PAR changes nasal air conditioning and to assess the relationship between nasal conditioning and nasal patency and geometry.

METHODS

Nineteen subjects with PAR were enrolled into this study. Measurement of nasal conditioning, active anterior rhinomanometry (AAR), acoustic rhinometry (AR), and clinical symptom evaluation were performed before and after nasal allergen challenge with allergen extracts from house dust mites.

RESULTS

Ten and 20 min after nasal allergen challenge, the total water content of the air measured in the nasopharynx and the water gradient across the nose were significantly higher in the nasal cavity in which the allergen extract was sprayed. The temperature on both sides of the nose increased non-significantly after nasal allergen challenge. No correlation to data obtained by AAR, AR, and clinical symptom evaluation after nasal allergen challenge was found.

CONCLUSION

We suggest that an increase in mucosal humidity due to the allergic provocation might be responsible for the increase in nasal conditioning capacity because no correlation to changes in nasal perimeter and patency was found.

Is there a causative role for tetanus toxoid vaccination in the development of allergy-like symptoms and in the increasing prevalence of atopic diseases?

Allergic diseases are a worldwide health problem. They mainly affect people living in developed countries where an increasing prevalence of allergy symptoms has been recorded in the last 20-30 years. The cause of this increase is still disputed, and, among others, the "hygiene hypothesis" supported the concept that relevant changes in lifestyle could have a relationship with the phenomenon. More recently the recorded parallel increase in autoimmune diseases has suggested to consider the "hygiene hypothesis" as a cause of a more general disregulation of the immune system leading to both allergy and to autoimmunity. Here are reported a series of observations, evidence, and data from the literature leading to a different hypothesis. The key points are: (1) the presence of two subsets of patients having allergy symptoms based on an IgE-mediated mechanism or not; (2) the positive results obtained with the autologous serum skin test in either cutaneous or respiratory affected subjects, mainly in children and adult females; (3) the presence of IgG autoantibodies against the alpha-chain of the high affinity IgE receptor (FcepsilonRIalpha) in non-IgE-mediated urticaria and even in respiratory subjects; (4) the cross-reactivity between epitopes of the tetanus toxoid molecule and the FcepsilonRIalpha detected by means of an alpha-chain affinity purified IgG fraction; (5) the positive skin reactivity obtained using IgG anti-tetanus toxoid preparations in allergic and non-allergic volunteers. The presence of IgG autoantibodies actively generated by the population-based vaccination with tetanus toxoid could induce both mediator release from activated mast cell and Th2 cytokine production early in life. There are epidemiological evidences that tetanus toxoid vaccination could be linked with an increased tendency to have allergy symptoms. The different epidemiological distribution of non-IgE-mediated symptoms, mainly affecting young infants would be in agreement with the present hypothesis. The prevalent mother-to-child relationship in terms of risk for allergy symptoms could be explained with the trans-placenta transfer of IgG. A similar transfer could also take place through the mother milk during breast feeding. It may thus be hypothesized that the increased prevalence of allergic diseases could be caused by the generalized tetanus toxoid immunization procedure, progressively extended to most of the countries worldwide in the last 30-40 years. Both the induction of non-IgE-mediated symptoms caused by the mast cell activation via the anti-FcepsilonRIalpha IgG and the long lasting Th2 inflammation of affected tissues would be the inducing mechanisms. This hypothesis would re-configure part of the allergic diseases as a Th2 phenotypic expression of an autoimmune disease.

The potential role of allergen-specific sublingual immunotherapy in atopic dermatitis

Atopic dermatitis is a chronic inflammatory skin disease associated with increasing prevalence, morbidity, and cost in developed Western countries. Frequently associated with respiratory allergy during adulthood, atopic dermatitis often represents the first phenotypic appearance of atopy in early childhood when the allergic 'march' starts and progressively moves toward food allergy, asthma, and rhinitis. At present, a consistent body of evidence supports the view that atopic dermatitis may represent the skin compartmentalization of a systemic allergic inflammation. Lymphocytes infiltrating early lesional skin express a T helper (Th) 2 pattern of cytokine secretion (increased levels of interleukin [IL]-4 and/or IL-13 and decreased levels of interferon-gamma) as well as the typical Th2-type chemokine receptor CCR4, specific to the thymus and activation-regulated chemokines. Keratinocytes from patients with atopic dermatitis produce thymic stromal lymphopoietin, a novel cytokine that supports the early lymphocyte development in mouse models, and activates dendritic cells involved in the pathogenesis of allergic diseases in humans. Increased levels of circulating hemopoietic precursor cells have been reported in atopic dermatitis, as in allergic asthma and rhinitis. Furthermore, the recognition of CD34+ hemopoietic precursor cells, and evidence for cellular differentiation/maturational events occurring within atopic dermatitis skin lesion infiltrates, are consistent with the recent reinterpretation of the Th2/Th1 paradigm, where Th2 cells appear to belong to the early stages and Th1 to the ultimate stages of a linear, rather than divergent, pattern of lymphoid differentiation. This more detailed understanding of the immunologic derangements contributing to the atopic dermatitis pathogenesis has led to growing interest in allergen-specific immunotherapy for the disease. Due to the complexity intrinsic to atopic dermatitis and the lack of consensus-based guidelines for standardized outcome measure, only eight studies are available in the literature for a qualitative evaluation of this treatment approach. Two of these studies were double blind and placebo controlled, and six were cohort studies. Immunotherapy was found to be effective in one controlled study and five observational reports. Uncertain results were provided by one low-powered, controlled study, and negative outcomes were raised by a unique study performed with oral immunotherapy, which is not an effective route of mucosal allergen administration. Thus, more efficacy studies are required before immunotherapy could be recommended for the routine treatment of atopic dermatitis. Allergen-specific sublingual immunotherapy, given its excellent safety profile and ability to interfere with the systemic aspects of allergic inflammation, appears a good potential candidate for the pathogenetic treatment of the disease.

Effects of fexofenadine and other antihistamines on components of the allergic response: adhesion molecules

Intercellular adhesion molecules (ICAMs), in particular ICAM-1, appear to play a crucial role in the recruitment and migration of inflammatory cells to the site of an allergic reaction. Glucocorticoids and allergen-specific immunotherapy have been shown to exert effects on selected components of this system, both in vitro and in vivo, but further research is required to better understand the effects of these therapies. Nasal and conjunctival challenge models (including natural and experimental allergen exposure) represent useful and safe tools for studying the activity of antiallergy drugs in vivo. These tests allow the investigation of a wide variety of parameters including inflammatory infiltrate, ICAM-1 expression, and changes in the concentration of soluble inflammatory mediators. With these tools, anti-inflammatory activity related to the modulation of epithelial cell adhesion molecules has been demonstrated in vivo for several H(1)-receptor antagonists (azelastine, cetirizine, loratadine, levocabastine, oxatomide, and terfenadine). Fexofenadine is a nonsedating, long-acting antihistamine with highly selective H(1)-receptor antagonist activity and a particularly favorable safety profile. In addition, fexofenadine has proven anti-inflammatory activity and has been shown to inhibit a number of mediators at clinically relevant concentrations, including in vitro inhibition of ICAM-1 expression on conjunctival and nasal epithelial cells.

Minimal persistent inflammation, an emerging concept in the nature and treatment of allergic rhinitis: the possible role of leukotrienes

OBJECTIVE

To review the emerging concept of minimal persistent inflammation in allergic rhinitis and its implications for therapy.

DATA SOURCES

Relevant clinical studies in the English language were reviewed.

STUDY SELECTION

Material was taken from academic/scholarly journals.

RESULTS

Accumulating evidence suggests that allergic rhinitis is a chronic inflammatory disease instead of a disease of acute symptoms. An approach to the therapy for allergic rhinitis should consider that even when symptoms are absent, a minimal level of persistent inflammation may persist. To prevent unexpected exacerbations, the treatment strategy may need to include managing subclinical persistent inflammation. Therapeutic options addressing the major inflammatory elements in allergic rhinitis, including eosinophils, the cysteinyl leukotrienes, and histamine, must be evaluated as management strategies that can achieve effective control. Traditional medications include intranasal corticosteroids, antihistamines, and immunotherapy. Recently, a leukotriene receptor antagonist has been approved for major rhinitis symptoms (congestion, rhinorrhea, sneezing, and pruritus), suggesting a new option for the treatment of allergic rhinitis.

CONCLUSIONS

Because of the possible presence of a minimal persistent inflammation during rhinitis patients' asymptomatic periods, it is important to consider a prophylactic approach to treating allergic rhinitis to prevent or reduce exacerbations during an acute increase in allergen. In light of the advances in the understanding of the pathogenesis of allergic rhinitis, agents must be considered based on their safety, efficacy, and ability to deal with underlying inflammation as well as symptom relief.

Validation of the classification of ARIA (allergic rhinitis and its impact on asthma)

BACKGROUND

Allergic rhinitis is commonly divided into seasonal and perennial rhinitis. The recent Allergic Rhinitis and its Impact on Asthma (ARIA) workshop proposes to replace these terms by intermittent vs persistent rhinitis.

METHODS

In order to test the new ARIA classification against the classical one used in medical practice in France, we designed two cross-sectional surveys: (i) a spring survey, where 1321 general practitioners enrolled 3026 patients consulting for seasonal allergic rhinitis and (ii) an autumn-winter survey, where 1346 doctors enrolled 3507 patients for perennial allergic rhinitis. Both doctors and patients filled out a specific questionnaire on allergic rhinitis.

RESULTS

Focusing on the number of days per week and consecutive weeks per year, the patients described the duration of their symptoms (based on an auto-questionnaire). About 43.7% of the patients, classified by their doctor as seasonal, did in fact have persistent rhinitis, whereas 44.6% classified as perennial had intermittent rhinitis.

CONCLUSIONS

The proposal of the ARIA expert panel defining the chronology of allergic rhinitis as number of days per week and consecutive weeks per year is likely to change daily physician practice.

Improvement of clinical and immunopathologic parameters in asthmatic children treated for concomitant chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis is frequently associated with asthma. A Th2 cytokine pattern has been recently reported in chronic rhinosinusitis in asthmatic children.

OBJECTIVE

To evaluate the effects of treating concomitant chronic rhinosinusitis on respiratory symptoms and function and immunopathological parameters in asthmatic children.

METHODS

Eighteen children with moderate asthma (age range, 5 to 12 years) poorly controlled by high doses of inhaled corticosteroids and chronic rhinosinusitis were evaluated for symptoms, spirometry, and inflammation at baseline, after treatment, and 1 month after suspension of treatment. All of the children were treated with a combination of amoxicillin and clavulanate (20 mg/kg twice daily) and fluticasone propionate aqueous nasal spray (100 microg/d) for 14 days. A short course of oral corticosteroids was also prescribed (deflazacort, 1 mg/kg daily for 2 days, 0.5 mg/kg daily for 4 days, and 0.25 mg/kg daily for 4 days). Rhinosinusal lavage for cytokine measurements and a nasal scraping for cytologic analysis were performed in all patients before and after medical treatment.

RESULTS

A negative endoscopy result was demonstrated in 15 children after treatment. Symptoms and respiratory function significantly improved after treatment and 1 month later; 8 children had intermittent asthma and 10 had mild asthma. A significant reduction of inflammatory cell numbers was detected in all asthmatic children. Interleukin 4 levels significantly decreased (P < 0.001), whereas interferon-y levels increased (P < 0.001).

CONCLUSION

Treatment of chronic rhinosinusitis is able to improve symptoms and respiratory function in asthmatic children, reducing inflammatory cells and reversing the cytokine pattern from a Th2 toward a Th1 profile.

Seasonal intestinal inflammation in patients with birch pollen allergy

BACKGROUND

The pathophysiologic interactions of inflammatory reactions between the mucosa of the respiratory tract and that of the gastrointestinal tract in individuals with allergy are poorly studied, despite the fact that allergic symptoms in the airways and the gastrointestinal tract might arise in the same patient.

OBJECTIVE

The objective of this study was to examine the inflammatory response histologically by enumerating eosinophils, IgE+ cells, and T cells in duodenal biopsy specimens in adult patients with IgE-mediated birch pollen allergy during the birch pollen season and off-season.

METHODS

Nine patients with birch pollen allergy verified by skin prick test and serum IgE antibodies were investigated toward the end of the birch pollen season and again 6 months later (off-season). Duodenal biopsy specimens were obtained and studied by immunostaining for the eosinophil major basic protein (MBP), IgE, and CD3+ T cells.

RESULTS

Oral allergy syndrome to birch-associated foods was present in all patients as indicated by questionnaire. Duodenal increases of MBP+ eosinophils and IgE-bearing cells were found in the patients during the birch pollen season as compared with off-season. No seasonal differences in the T-cell numbers in these patients were seen. Off-season, there was no significant difference between the patients and the control subjects regarding the intestinal frequencies of MBP+ eosinophils, mucosal IgE+ cells, and T cells.

CONCLUSION

Birch pollen exposure triggered a local inflammation with an increase in duodenal eosinophils and IgE-carrying mast cells in patients with allergy. Our study gives evidence for the interplay between immunologically active cells in the airways and the gut.

Introduction to nasal and pulmonary allergy cascade

The early phase of an IgE-dependent allergic reaction is followed by the activation of a complex network of inflammatory phenomena - T lymphocytes, cytokines, mediators, and adhesion molecules - that mediate late and ongoing allergic symptoms. The kinetics of respiratory inflammation following allergen exposure involve the migration of inflammatory cells to the mucosa within about 30 min, increased inflammatory infiltration over the following hours, and then slow subsidence. A relationship between asthma and allergic rhinitis is supported by epidemiological, histological, physiological, and immunopathological data, and by the response of asthma symptoms in rhinitic patients to intranasal corticosteroids and antihistamines. For example, there is no morphological difference between the bronchial inflammatory response following allergen-specific challenge in patients suffering from asthma alone or rhinitis alone. It is the allergen dose that makes the difference in the airway response to allergen in allergic rhinitis and asthma. Recognition of the relationship between asthma and allergic rhinitis has led to the introduction of new diagnostic terminology and treatment recommendations: 1) patients with persistent rhinitis should be evaluated for asthma; 2) patients with persistent asthma should be evaluated for rhinitis; and 3) a strategy should combine the treatment of upper and lower airways in terms of efficacy and safety.

Systemic reactions to immunotherapy: influence of composition and manufacturer

BACKGROUND

Although immunotherapy clearly demonstrated the benefit of reducing allergic symptoms, it has the drawback of adverse events, mainly systemic reactions that could be very inconvenient for patients and even life-threatening.

OBJECTIVE

The aim of the present study was to assess the incidence of systemic reactions to immunotherapy in a large number of patients, and its potential relationship with the characteristics of therapy, such as allergen composition or manufacturing laboratory.

METHODS

This study analysed the administration of specific immunotherapy during a period of 5 years, involving 1212 patients affected by respiratory hypersensitivity or hymenoptera venom anaphylaxis. Commercial extracts were supplied by five different laboratories. All the patients were attended at an out-clinic immunotherapy unit by the same experienced staff. Immunotherapy was given following a conventional schedule, modified according the usual recommendations.

RESULTS

A total of 250 adverse reactions have been recorded, resulting in a frequency of 0.84% over the total number of injections. Seventy-nine of them (32%) were systemic reactions (0.27% SR/injection). The 79 systemic reactions were observed in 60 patients (5% of the patients). The frequency of systemic reactions was significantly lower (P < 0.01) on the group of mites than on the other groups. The frequency of systemic reactions varies according to the manufacturing laboratory. In the case of mite extracts, although one of the laboratories had a lower frequency of adverse systemic reactions, it did not reach the level of statistical significance. However, in relation to pollen extracts, preparations of one of the manufacturers had a significantly lower frequency of systemic reactions. Concerning the time of occurrence, 27% of systemic reactions were delayed, thus they appeared at least 30 min after the vaccine injection, most of them due to pollen extracts.

CONCLUSION

This is a preliminary study to evaluate the factors that could facilitate the appearance of systemic reactions demonstrating that not only the composition but also the manufacturer is connected to systemic reactions. Although further studies are needed to clearly establish the influence of manufacturer on frequency and time of appearance of systemic reactions, it seems necessary to reach a wide consensus on allergen extract standardization methods.

Topical azelastine in perennial allergic conjunctivitis

OBJECTIVE

Azelastine is a selective H(1)-receptor antagonist that inhibits histamine release and interferes with activation of several other mediators of allergic inflammation. Together with demonstrated efficacy in seasonal allergic conjunctivitis, azelastine indicated a therapeutic potential for perennial allergic conjunctivitis (PAC). The present study aimed to evaluate azelastine eye drops in patients with PAC compared to placebo.

RESEARCH DESIGN AND METHODS

A multinational trial in 22 centres randomised 139 patients to twice-daily treatment for 6 weeks with masked 0.05% azelastine eye drops, matching masked placebo, or open-label levocabastine. Randomisation required a sum itching and conjunctival redness score of at least 3 (0-6 scale) after 1 week of placebo. The change in sum score was evaluated during treatment.

RESULTS

Azelastine significantly improved itching and conjunctival redness compared to placebo (p < 0.001) with global tolerability that was not substantially different from placebo. On day 7, the mean symptoms sum score improved with azelastine by 1.9 +/- 1.1 and with levocabastine by 1.5 +/- 1.2 compared to placebo (0.6 +/- 1.1) from baseline values of 3.7-3.8. The sum scores continued to improve up to day 42. Daily patient logs confirmed the clinically assessed scores. Most frequent adverse events following azelastine were bitter taste and application site reaction.

CONCLUSIONS

Topical azelastine progressively improved itching and conjunctival redness in PAC patients compared to placebo and was at least as effective as levocabastine. Rapid relief is consistent with H(1)-receptor antagonist action, while continued improvement up to 6 weeks may be consistent with mechanisms involving other mediators of allergic inflammation.

CD34+ cells in peripheral blood of healthy human beings and allergic subjects: clue to acute and minimal persistent inflammation

BACKGROUND

There is compelling evidence that hemopoietic precursor cells (HPC) play a crucial role in establishing cellular inflammation in allergic diseases. Increased levels of circulating CD34+ HPC committed to the myeloid lineage have been extensively reported in allergic rhinitis, asthma and eczema, whereas CD34+ cells have been identified within the cellular infiltrates of tissues, at peripheral sites of inflammation.

METHOD

We conducted a pilot study to evaluate CD34+ traffic in the peripheral blood of 22 consecutive patients (13 men and nine women; mean age 28.9 years), independently of treatment. The patients presented rhinitis, asthma, eczema, urticaria and adverse food reactions of suspected allergic origin. Allergic reactions were extrinsic in 18 patients and intrinsic in four. In 12 patients who underwent sublingual specific immunotherapy, CD34+ cells were quantified at enrollment (T0), one year later (T1) and two years later (T2). The severity of symptoms was graded on a five-point scale (0 = absence of symptoms and 4 = severe symptoms). Twenty healthy human subjects (10 men and 10 women; mean age 24.5 years) were evaluated as controls. To obtain information about the total amount of circulating HPC, independently of the lineage commitment (Lin+/-) and the degree of differentiation (CD34bright/dim), we used a modification of the Milan protocol of peripheral blood CD34+ cell estimation. The cells were analyzed using a BD FACScan or FACSCalibur and the results were expressed as the percentage of positive cells.

RESULTS

CD34+ cell traffic in the control group was very low since all values were < 0.10 (median value: 0.03 %). Values in the patient group were increased in both extrinsic and intrinsic forms with a median value of 0.25 % (interquartile range: 0.13- 0.33 %). The relationship between CD34+ traffic and the severity score was highly significant (Spearman's rho = 0.954; test of Ho: CD34; independent score: Pr > t = 0.000).

CONCLUSIONS

The data reported herein suggest that the method employed is effective in assessing acute allergic inflammation, as well as minimal persistent inflammation underlying an asymptomatic clinical condition. Evaluation of CD34bright/dim peripheral traffic, if confirmed by the outcomes of a multicenter study currently being planned together with traditional study of circulating IgE, could be a reliable non-invasive laboratory tool for monitoring allergic inflammation.

Local IgE synthesis in allergic rhinitis and asthma

Local IgE production has been a contentious concept for over 40 years. Although a host of clinical observations suggested a local source of IgE, co-localization of IgE to B cells in the nasal mucosa could not be demonstrated. In contrast, igE-producing B cells were observed in local lymphoid tissue. Definitive proof of local IgE synthesis in the nasal mucosa has now become available. Here, we review the recent developments in local IgE research in allergic rhinitis and asthma within their historical context, and speculate on the implications of both local IgE synthesis and ongoing research into local immunoglobulin isotype switching for patient therapy.

Cytokine pattern in allergic and non-allergic chronic rhinosinusitis in asthmatic children

BACKGROUND

Rhinosinusitis represents one of the most common chronic diseases. The association of rhinosinusitis with asthma has been frequently reported. Eosinophils and Th2 cells play a pathogenic mechanism in asthma.

OBJECTIVE

The aims of the study were to evaluate the cytokine pattern in chronic rhinosinusitis in asthmatic children and to compare the findings in allergic vs. non-allergic asthmatics.

METHODS

Thirty-five asthmatic children were evaluated, 19 males and 16 females, with an average age of 8.7 years. All children were asthmatic and suffered from chronic rhinosinusitis. Twenty were allergic and 15 were non-allergic. Ten healthy children were studied as normal controls. Evaluated parameters were the levels of the following cytokines: IL-1beta, IL-4, IL-6, IL-8, IL-12, IFN-gamma and TNF-alpha. Cytokines were recovered from rhinosinusal lavage and measured by immunoassays. Nasal cytology was also performed in all subjects and inflammatory cells were counted by conventional staining.

RESULTS

Allergic subjects showed a significant increase of IL-4 (P < 0.01) and TNF-alpha (P < 0.05) and a significant decrease of IL-12 (P < 0.05) and of IFN-gamma (P < 0.0001), whereas IL-1beta, IL-6 and IL-8 were not significantly increased. Non-allergic children showed a significant increase of IL-4 (P < 0.05) and a significant decrease of IFN-gamma (P < 0.0001), IL-12 was not significantly decreased, and IL-1beta, IL-6 and IL-8 were not significantly increased. A significant inflammatory infiltrate was present in all asthmatic children. Significant correlations were demonstrated between IL-4 and IL-12 (P < 0.001), IL-12 and IFN-gamma (P < 0.001), IL-8 and neutrophils (P < 0.01), and TNF-alpha and monocytes/macrophages (P < 0.05), in allergic asthmatics. IL-4 and IL-12 were significantly correlated (P < 0.05) as well as IL-8 and neutrophils (P < 0.01) in non-allergic asthmatics.

CONCLUSION

This study shows that allergic asthmatic children with chronic rhinosinusitis have a typical Th2 cytokine pattern, but also non-allergic asthmatic children share a similar pattern. These findings would suggest the existence of a common pathophysiological mechanism shared by upper and lower airways and are consistent with the concept of united airways disease.

Fexofenadine reduces nasal congestion in perennial allergic rhinitis

BACKGROUND

Nasal congestion is the predominant symptom in perennial allergic rhinitis (PAR), and it seems to be mainly related to the late-phase inflammatory events. The present pilot study aimed to evaluate the therapeutic effect exerted by fexofenadine in patients with PAR due to mite allergy.

METHODS

This study was a parallel, double-blind, randomized, three-arm (1:1:1), placebo-controlled study. Thirty-one subjects with PAR were enrolled and received double-blind medication: fexofenadine 120 or 180 mg, or placebo, once a day for 28 days.

RESULTS

The total symptom score was reduced by fexofenadine (both dosages) at V2 (P=0.007), whereas placebo did not modify it. Nasal congestion decreased after 1 week of treatment with fexofenadine 120 (P=0.027) and 180 (P=0.01), but not with placebo (P=NS). At V3, fexofenadine (both dosages) significantly reduced nasal congestion (P=0.011 and P=0.007, respectively), by placebo did not show any significant effect.

CONCLUSIONS

This pilot study represents the first evidence of the efficacy of fexofenadine in PAR, and also the control of the nasal congestion. We suggest performing larger trials to confirm these preliminary findings.

Long-term cetirizine treatment reduces allergic symptoms and drug prescriptions in children with mite allergy

BACKGROUND

Experimental data demonstrate that mite allergy is characterized by persistent chronic inflammation, even during asymptomatic periods. This suggests that long-term continuous treatment be included in the global strategy of allergy treatment.

OBJECTIVE

We conducted a study to evaluate whether regularly administered cetirizine reduces allergic symptoms and drug prescriptions in children with mite allergy.

METHODS

In this double-blind, randomized, placebo-controlled study, two parallel groups of 10 children with mite allergy (mean age: 6.5 years) received either cetirizine or placebo daily for 6 months. Participants were allowed to take rescue medications for rhinitis and/or mild asthma. The symptoms (nasal itching, sneezing, obstruction, rhinorrhea, conjunctival itching, lacrimation, conjunctival hyperemia, cough, wheezing, and chest tightness) were recorded on a diary card. The intake of cetirizine (as additional symptomatic treatment), antibiotics, acetaminophen, beta2-agonists, inhaled and systemic corticosteroids was also recorded.

RESULTS

Symptom scores and drug consumption were significantly lower (P < 0.05) in the cetrizine-treated group versus the placebo group. The greatest reductions were in cetirizine itself, inhaled corticosteroids, beta2-agonists, and antibiotics. No side effects were reported in either group.

CONCLUSIONS

In mite-allergic children, cetirizine administered daily for prolonged periods decreases symptoms of and drug prescriptions for allergic rhinitis and asthma compared with symptomatic treatment.

Pediatric allergic rhinitis and comorbid disorders

Allergic rhinitis (AR) is rarely found in isolation and needs to be considered in the context of systemic allergic disease associated with numerous comorbid disorders, including asthma, chronic middle ear effusions, sinusitis, lymphoid hypertrophy with obstructive sleep apnea, disordered sleep, and consequent behavioral and educational effects. The coexistence of AR and asthma is complex. First, the diagnosis of asthma may be confounded by symptoms of cough caused by rhinitis and postnasal drip. This may lead to either inaccurate diagnosis of asthma or inappropriate assessment of asthma severity with over treatment of the patient. The term "cough variant rhinitis" is therefore proposed to describe rhinitis that manifests itself primarily as cough that results from postnasal drip. AR, however, also has a causal role in asthma; it appears both to be responsible for exacerbating asthma and to have a role in its pathogenesis. Postnasal drip with nasopharyngeal inflammation leads to a number of other conditions. Thus sinusitis is a frequent extension of rhinitis and is one of the most frequently missed diagnoses in children. Allergen exposure in the nasopharynx with release of histamine and other mediators can cause Eustachian tube obstruction possibly leading to middle ear effusions. Chronic allergic inflammation of the upper airway causes lymphoid hypertrophy with prominence of adenoidal and tonsillar tissue. This may be associated with poor appetite, poor growth, and obstructive sleep apnea. AR is therefore part of a spectrum of allergic disorders that can profoundly affect the well being and quality of life of a child. Prospective cohort studies are required to assess the disease burden caused by AR in childhood and to further assess the potential educational impairment that may result. Because AR is part of a systemic disease process, its management requires a coordinated approach rather than a fragmented, organ-based approach.

Nasal endoscopy in asthmatic children: assessment of rhinosinusitis and adenoiditis incidence, correlations with cytology and microbiology

BACKGROUND

Upper respiratory airway diseases may induce a worsening of asthma. Sinusitis represents one of the most common chronic diseases. The association of asthma and sinusitis varies greatly in different studies, depending on diagnostic procedures.

OBJECTIVE

The aims were: (i) to demonstrate that nasal endoscopy may be easily feasible in asthma at paediatric age; (ii) to evaluate the incidence of rhinosinusitis and adenoiditis in children with asthma by nasal endoscopy; (iii) to correlate inflammatory parameters such as cytology and microbiological cultures with nasal endoscopy findings.

SUBJECTS AND METHODS

One hundred and forty-five asthmatic children were evaluated, 48 males and 97 females, with an average age of 7.27 years. Evaluated parameters were the incidence of rhinosinusal infections in asthmatic children, and the role of: (i) nasal endoscopy, (ii) nasal cytology, and (iii) nasal microbiology in their diagnoses.

RESULTS

Nasal endoscopy was successfully performed on 128 patients. Twenty-six children had endoscopic rhinosinusitis alone, 10 had adenoiditis alone, and 35 showed endoscopic rhinosinusitis associated with adenoiditis. There were significant correlations between endoscopic rhinosinusitis and adenoiditis (P < 0.001), between clinical and endoscopic rhinosinusitis (P < 0.001), between endoscopic rhinosinusitis and adenoiditis and microbiology (P < 0.05 and P < 0.0001, respectively), and between microbiology and cytology (P < 0.05).

CONCLUSION

This study shows that rhinosinusal infections are common in asthmatic children. Moreover, nasal endoscopy might represent a fruitful tool in the management of asthmatic children.