Local IgE in non-allergic rhinitis

Yingxiang Acupoint Embedding Improves Mucosal Barrier Function in Rats with Local Allergic Rhinitis

INTRODUCTION

Epithelial barrier disruption is the initial cause of various diseases. We previously reported that acupoint catgut embedding (AE) improves tight junction proteins (TJs) in rats with allergic rhinitis. However, whether AE improves the epithelial barrier in local allergic rhinitis (LAR) remains unknown.

METHODS

A total of 36 Sprague Dawley (SD) male rats aged 5-7 weeks were divided into 6 groups with 6 rats each: control group, LAR model group, false acupoint embedding + LAR group, acupoint embedding + LAR group, capsaicin + LAR group, and tunicamycin + acupoint embedding + LAR group. Behavioral observation, ELISA to detect inflammatory factors in nasal lavage fluid and serum IgE, nasal mucosal permeability test, hematoxylin-eosin staining, PCR to detect Substance P (SP), Western blot, and immunofluorescence to detect endoplasmic reticulum stress (ERS) index and TJs were used to investigate the mechanism of AE in LAR.

RESULTS

AE improved the symptoms and pathological features of nasal mucosa of LAR rats, reduced the inflammatory factors (IL4, IL5, IL13) of nasal lavage fluid, and showed no significant change in serum IgE levels in all groups. In addition, AE decreased the expression of SP in nasal mucosa of LAR rats, inhibited ERS, increased the expression of tight junction protein, reduced the permeability of nasal mucosa, and improved the function of nasal mucosal barrier.

CONCLUSION

This study confirms that AE can improve the nasal mucosal barrier function of LAR by reducing the expression of SP, inhibiting ERS and increasing the expression of TJs, thus enhancing the nasal mucosal barrier function.

Role of autophagy and mitophagy of group 2 innate lymphoid cells in allergic and local allergic rhinitis

Background

Roles of ILC2s in allergic rhinitis (AR) and local allergic rhinitis (LAR) are unclear. In this study, we are determined to find the levels of autophagy and mitophagy of ILC2s in allergic nasal inflammation.

Methods

ELISA was used to detect type 2 inflammatory cytokines. Hematoxylin and eosin (H&E) staining were used to compare the eosinophil (EOS) infiltration of nasal tissue specimens. Flow cytometry was used to detect the levels of ILC2s and Th2 cells. Immunohistochemistry (IHC) and Western blot (WB) were used to detect the levels of Beclin1, LC3, p62, PINK1, Parkin, FUNDC1, and BNIP3 in nasal mucosa. The levels of autophagy related proteins and mitophagy related proteins of the ILC2s were detected by WB. The number of autophagosomes of ILC2s was observed by transmission electron microscopy. The co-localization levels of GFP-LC3 and Mito tracker in ILC2s were observed by confocal microscopy using immunofluorescence.

Results

We found that the level of type 2 inflammation in AR and LAR mice was significantly increased. The levels of autophagy and mitophagy of AR and LAR mice in nasal mucosa and ILC2s were both increased.

Conclusions

ILC2s may be associated with the occurrence and development of nasal allergic inflammation. The abnormal increase of autophagy and mitophagy levels in the nose may be associated with the incidence of AR and LAR. Abnormal autophagy and mitophagy levels of ILC2s cells may be one of the causes of allergic nasal inflammation.

Nasal eosinophilia as a preliminary discriminative biomarker of non-allergic rhinitis in every day clinical pediatric practice

BACKGROUND

Non-allergic rhinitis (NAR) in children, named local allergic rhinitis (LAR) and non-allergic rhinitis with eosinophilia syndrome (NARES), are recently termed entities in childhood characterized by symptoms suggestive of allergic rhinitis in the absence of systemic atopy. Nasal eosinophils (nEo) are the principal cells involved in the allergy inflammation and nasal allergen provocation test is the gold standard method for the diagnosis, albeit with several limitations. The aim of this study was to validate the presence of nEo in combination with the therapeutic response to nasal steroids, as a preliminary discriminator of NAR in real life data.

METHODS

In a prospective cohort study, 128 children (63.3% male, aged 72 ± 42 m) with history of NAR were enrolled and followed up for 52 ± 32 m. Nasal cytology was performed and nasal steroids trial was recommended initially in all and repeatedly in relapsing cases. Response to therapy was clinically evaluated using 10-VAS.

RESULTS

Significant nEo was found in 59.3% of the cases and was related to reported dyspnea episodes. 23.4% had no response to therapy, whereas 51.5% were constantly good responders. Response to therapy was related to nEo and a cutoff point of 20% was defined as the most reliable biological marker with 94% sensitivity and 77% specificity.

CONCLUSIONS

In children with symptoms of NAR, the presence of nEo > 20% constantly responding to nasal steroid therapy, is a clear indicator of atopy. In an everyday clinical setting, it emerged as an easy, preliminary, cell biomarker suggestive of further investigation such as NAPT, to discriminate LAR from NARES.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

The Role of Nasal Cytology and Serum Atopic Biomarkers in Paediatric Rhinitis

A Nasal Provocation Test allows the differentiation of allergic and non-allergic rhinitis, but it is difficult and expensive. Therefore, nasal cytology is taking hold as an alternative. We carried out a cross-sectional study, including 29 patients with persistent rhinitis according to ARIA definition and negative skin prick tests. Nasal symptoms were scored from 0 to 5 using a visual analogue scale, and patients underwent blood tests to investigate blood cell count (particularly eosinophilia and basophilia), to analyze serum total and specific IgE and eosinophil cationic protein (ECP), and to perform nasal cytology. We performed a univariate logistical analysis to evaluate the association between total serum IgE, serum eosinophilia, basophils, and ECP and the presence of eosinophils in the nasal mucosa, and a multivariate logistic model in order to weight the single variable on the presence of eosinophils to level of the nasal mucosa. A statistically significant association between serum total IgE levels and the severity of nasal eosinophilic inflammation was found (confidence interval C.I. 1.08-4.65, odds ratio OR 2.24, p value 0.03). For this reason, we imagine a therapeutic trial with nasal steroids and oral antihistamines in patients with suspected LAR and increased total IgE levels, reserving nasal cytology and NPT to non-responders to the first-line therapy.

Rhinitis phenotypes and multimorbidities in the general population: the CONSTANCES cohort

BACKGROUND

Scarce epidemiological studies have characterised allergic rhinitis (AR) and non-allergic rhinitis (NAR) in adults. In a population-based cohort, our aims were to 1) describe rhinitis, AR and NAR, and 2) explore how asthma and conjunctivitis may lead to the identification of novel rhinitis phenotypes.

METHODS

In this cross-sectional analysis, current rhinitis was defined as present in the last 12 months using a questionnaire from the French CONSTANCES cohort. Participants with current rhinitis reporting nasal allergies were considered as AR, otherwise as NAR. We described AR and NAR phenotypes, and their phenotypes including co-occurrence with ever-asthma and ever-conjunctivitis.

RESULTS

Among the 20 772 participants included in this analysis (mean±sd age 52.6±12.6 years; 55.2% female), crude prevalences of AR and NAR were 28.0% and 10.9%. AR participants more frequently reported persistent rhinitis (31.6% versus 25.1%) and moderate-to-severe rhinitis (40.1% versus 24.2%) than NAR participants. Among AR or NAR participants, those with ever-asthma reported more moderate-to-severe rhinitis. Participants with AR, ever-asthma and ever-conjunctivitis had an earlier age of rhinitis onset, more severe rhinitis and higher eosinophil counts than participants in other groups. Results were replicated in another cohort.

CONCLUSIONS

In this large population-based cohort, 40% reported current rhinitis, with a lower prevalence of moderate-to-severe rhinitis than in clinical practice. For the first time in a general adult population, we showed that AR and NAR alone or in combination with asthma or in combination with asthma and conjunctivitis are different phenotypes. These results provide new insights on how best to manage rhinitis and its multimorbidities.

Skin Testing Is Useful in Assessing Aeroallergen Sensitization in IgE Deficient Patients with Environmental Allergy-Like Symptoms

BACKGROUND

The value of aeroallergen skin testing is not known in IgE deficient individuals (IgE<2.5 kU/L).

OBJECTIVE

To investigate the utility of skin prick (SPT), intradermal skin testing (IDST) and measuring serum specific IgE (ssIgE) in IgE deficient patients presenting with environmental allergy-like symptoms.

METHODS

Individuals with IgE deficiency who had both SPT and IDST performed between 2010 to 2020 were matched (age and gender) to three different groups of non-IgE deficient patients with IgE≥2.5 kU/L (normal IgE [2.5 ≤ IgE<100], high IgE [100≤IgE<1000] and very high IgE levels [≥1000 kU/L]) who also had skin testing performed for evaluation of environmental allergy-like symptoms.

RESULTS

Among 34 IgE deficient patients who completed SPT and IDST, 52.9% (18/34) had at least one positive skin test (4 ± 3 positive tests/patient), compared with 91.2% in those with normal, 94.1% with high or 97.1% with very high IgE levels (p < 0.01). In contrast, only one of the IgE deficient patients had detectable ssIgE, while ssIgE levels were significantly higher in all other IgE subgroups. Allergic immunotherapy was prescribed for 22.2% of the IgE-deficient patients with positive skin tests, similar to those with normal (2/31, 6.5%, p = 0.21), high IgE (9/32, 28.1%, p = 0.25) and very high IgE levels (8/33, 23.5%, p = 0.07), with similar efficacy in their symptoms control.

CONCLUSION

Individuals with IgE deficiency may present with environmental allergy-like symptoms. A combination of SPT and IDST is useful for diagnosing aeroallergen sensitizations in these patients, indicating the presence of skin mast cell-bound IgE in some of these individuals, despite very low serum IgE levels. Further studies are needed to assess the exact significance of positive skin tests and the benefits of immunotherapy in this group.

The Role of Allergen-Specific Immunotherapy in ENT Diseases: A Systematic Review

Previous studies have demonstrated that both subcutaneous (SCIT) and sublingual specific immunotherapy (SLIT) are effective in treating allergic rhinitis (AR). Further studies have evaluated the efficacy of allergen-specific immunotherapy (AIT) on different ear, nose, and throat (ENT) manifestations, in which allergy might have an etiopathogenetic role, such as local allergic rhinitis (LAR), rhinosinusitis (RS), otitis media (OM), and adenotonsillar (AT) disease. Nevertheless, the management of allergy in ENT diseases is still debated. To the best of our knowledge, this is the first systematic review assessing the efficacy of AIT in ENT diseases aside from AR. Literature data confirmed that AIT might be an effective therapeutic option in LAR, although its effect is restricted to studies with short-term follow-up. Furthermore, previous research demonstrated that AIT may improve symptoms and surgical outcomes of chronic rhinosinusitis when used as an adjunctive treatment. Few studies supported the hypothesis that AIT may exert positive therapeutic effects on recurrent upper airway infections as adenotonsillar disease. Finally, some clinical observations suggested that AIT may add some benefits in the management of otitis media with effusion (OME). The results of this systematic review allow us to conclude that the efficacy of AIT in ENT disorders has been only slightly investigated and additional studies are needed.

Risk of Chronic Rhinosinusitis With Nasal Polyps in Endotypes of Dermatophagoides pteronyssinus-Induced Rhinitis

BACKGROUND

Observation of the natural history of two emerging endotypes of allergic rhinitis, local-sensitization rhinitis (LAR) and dual-allergic rhinitis (DAR), compared with systemic-sensitization rhinitis (AR), could improve knowledge of the role of allergy in chronic rhinosinusitis with nasal polyps (CRSwNP).

OBJECTIVE

To test the hypothesis that endotypes of Dermatophagoides pteronyssinus (DP)-induced rhinitis were risk factors for CRSwNP and adult-onset asthma and to investigate whether delayed hypersensitivity to DP, assessed by atopy patch test, could be a contributing factor.

METHODS

We conducted a prospective observational study over 15 years on a cohort of 999 patients: 468 with AR, 333 with LAR, and 198 with DAR. The latter endotype was characterized by the coexistence of seasonal disease caused by systemic sensitization to pollen in patients with DP-induced LAR. The study design included a physical visit; ear, nose, and throat examination with anterior rhinoscopy; skin prick test; serum-specific IgE; DP-atopy patch test; nasal allergen provocation test with DP; paranasal sinuses computed tomography scan; nasal endoscopy; and spirometry.

RESULTS

During 15 years of follow-up, 194 patients developed CRSwNP with a higher rate of LAR (28.2%) and DAR (22.2%) than AR (12%). For LAR and DAR, 7.5% and 10.6% of patients developed adult-onset asthma temporally linked to CRSwNP in 68% and 71.4% of cases, respectively. A total of 858 patients with rhinitis had delayed hypersensitivity to DP. Moreover, DP-ATP was an independent predictive factor for CRSwNP and had elevated positive and negative predictive values for localized allergic disease of the nasal mucosa.

CONCLUSIONS

Endotypes of DP-induced allergic rhinitis represent risk factors for CRSwNP. Patients with local-sensitization rhinitis and DAR are more at risk than those with AR. In these emerging endotypes, progression toward CRSwNP is often associated with the development of adult-onset asthma. Chronic rhinosinusitis with nasal polyps shows several possible indicators for type 2 endotype. Delayed hypersensitivity to DP is an independent predictive factor for CRSwNP.

Ragweed sublingual immunotherapy (SLIT) tablets in allergic rhinoconjunctivitis: a systematic review and meta-analysis

PURPOSE

Ragweed allergen causes Allergic rhinoconjunctivitis and sublingual immunotherapy is one of the treatment modalities to desensitize allergic individuals. This systematic review assesses the effectiveness and safety of sublingual immunotherapy for allergic rhinoconjunctivitis caused due to Ragweed.

METHODS

The databases search was done through December 2020. English-language randomized controlled trials were included if they compared sublingual immunotherapy with placebo, pharmacotherapy, or other sublingual immunotherapy regimens, and reported clinical outcomes. The strength of the evidence for each comparison and outcome was graded based on the risk of bias, consistency, magnitude of effect, and the directness of the evidence.

RESULTS

The searches performed according to the protocol identified 134 abstracts of which 67 were duplicates. A total of 37 full papers were therefore reviewed of which 5 were included for the final study. Participants' ages ranged from 4 to 58 years. The risk of bias was low in most studies. The review suggests that sublingual immunotherapy improves rhinoconjunctivitis symptoms, with 4 of 4 studies reporting efficacy showed improvement in the symptom score of SLIT groups compared to placebo. Local reactions were frequent, but anaphylaxis was not reported in any of the studies. Serious adverse events were very few in all the studies.

CONCLUSIONS

The overall evidence showed the effectiveness of sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis with or without asthma, but high-quality studies are still needed to answer questions regarding optimal dosing strategies.

Diagnosis and Treatment of Local Allergic Rhinitis

Some patients with chronic rhinitis have a positive nasal allergen provocation test (NAPT) without systemic IgE sensitization by skin prick tests or serum allergen-specific IgE (sIgE). This novel concept is called local allergic rhinitis (LAR) and affects children and adults worldwide, but is underdiagnosed. LAR is not just the initial state of allergic rhinitis (AR), it is a unique form of chronic rhinitis that is neither classical AR nor non-AR. Many of the features of AR and LAR are similar, such as a positive NAPT, positive type 2 inflammatory markers, including the nasal discharge of sIgE, and a high incidence of asthma. A differential diagnosis of LAR needs to be considered in patients with symptoms suggestive of AR in the absence of systemic atopy, regardless of age. The diagnostic method for LAR relies on positive responses to single or multiple allergens in NAPT, the sensitivity, specificity, and reproducibility of which are high. The basophil activation test and measurement of IgE in nasal secretions also contribute to the diagnosis of LAR. Treatment for LAR is similar to that for AR and is supported by the efficacy and safety of allergen exposure avoidance, drug therapy, and allergen immunotherapy. This review discusses current knowledge on LAR.

An integrative review on the uses of plant-derived bioactives formulated in conventional and innovative dosage forms for the local treatment of damaged nasal cavity

Plants and their derivates have been used as medicines for centuries and today is being re-discovered their usefulness for the human health. The therapeutic properties of phytochemicals are re-evaluated under the light of medical and pharmacological research, pushed by a constantly growing market demand, where consumers trust more natural products than synthetic drugs. New studies are enlightening the effectiveness of phytochemicals against a wide range of ailments, nevertheless very few evaluate the efficacy of topical formulations based on natural bioactive molecules in the treatment of nasal mucosal diseases. This review aims at exploring this little covered topic. An overview on the properties and functionality of the nasal mucosa and the different diseases affecting it has been provided. We summarized various nasal dosage forms containing natural bioactive and explored how innovative delivery systems loading phytochemicals can improve the treatment results. Finally, the potential use of novel nanocarriers for the treatment of nasal ailments has been covered as well.

Efficacy and Safety of Subcutaneous Immunotherapy for Local Allergic Rhinitis: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Subcutaneous immunotherapy (SCIT) has been used for treating local allergic rhinitis (LAR) patients. However, the clinical efficacy and safety were still questioned.

OBJECTIVE

This study was designed to estimate the efficacy and safety of SCIT for treating LAR patients through meta-analysis.

METHODS

We systemically searched MEDLINE, Cochrane Library, and Embase publications. Randomized, double-blind, clinical trials for the efficacy and safety of Allergen Immunotherapy (AIT) for LAR were included. A meta-analysis of 4 clinical endpoints (combined symptom and medication scores [CSMS], symptom scores [SS], medication scores [MS] and rhinoconjunctivitis quality of life questionnaire [RQLQ]) and adverse events (AEs)) was performed after bias and heterogeneity assessments. The immunologic response results were summarized.

RESULTS

Four RCTs with 134 patients were included. Four studies for analyzing primary outcomes (CSMS, SS, MS) and AEs, three for RQLQ results. The results indicated an important significant difference between SCIT and placebo groups, list as follows: CSMS (SMD = -2.42, 95% CI: -3.60 to -1.25, P < .0001), SS (SMD = -2.08, 95% CI -3.68 to -0.48, P = .01), MS (SMD = -1.43, 95% CI: -2.65 to -0.21, P = 0.02), RQLQ (SMD = -0.70, 95% CI -1.29 to -0.12, P = .02), Local AEs (RR = 4.13, 95% CI 1.08 to 15.77, P = .04). For immunologic response, significantly increased serum sIgG4 levels and improvements of allergen tolerance was observed after SCIT.

CONCLUSIONS

Our meta-analysis suggests that SCIT has a significant effect on improving symptoms and reducing medicine consumption for LAR patients. Larger and multicenter clinical trials are needed to clarify the safety and long-term efficacy.

The Importance of Nasal Provocation Testing in the Diagnosis of Dermatophagoides pteronyssinus-Induced Allergic Rhinitis

BACKGROUND

Allergen identification is the first step for allergen-specific immunotherapy (AIT) of allergic rhinitis (AR). Currently, the diagnosis of AR is based mainly on the positive results of the skin prick test (SPT) and/or serum specific immunoglobulin E (sIgE) measurement. However, the results of these two tests may not always directly correlate with AR.

OBJECTIVE

To investigate the importance of nasal provocation testing (NPT) in the diagnosis of Dermatophagoides pteronyssinus (Der p)-induced AR.

METHODS

Rhinitis patients willing to undergo AIT (n = 171) were enrolled. The correlations of Der p SPT, sIgE, NPT, and clinical symptom severity were assessed.

RESULTS

NPT-positive responses were more common in patients with higher SPT and sIgE levels. The optimal cut-off value for a NPT-positive response for SPT was 5.5 mm and for sIgE was 2.77 kUA/L, based on the respective receiver operating characteristic (ROC) curves. The area under the curve (AUC) of the ROCs was 0.814 (SPT only) and 0.794 (sIgE only) and increased to 0.828 with the combination of SPT and sIgE. The Der p-NPT concentration was inversely correlated with SPT and sIgE levels (r = -0.477, P < .001, and r = -0.461, P < .001, respectively), but none was correlated with the total nasal symptom score.

CONCLUSION

For patients who are willing to receive Der p AIT, NPT is a useful and safe test to confirm diagnosis prior to treatment initiation, especially in patients with lower levels of Der p SPT (< 5.5 mm) or sIgE (< 2.77 kUA/L).

Japanese cedar pollen upregulates the effector functions of eosinophils

Background

Symptoms of rhinitis and asthma can be exacerbated during Japanese cedar pollen (JCP)-scattering season, even in subjects who are not sensitized to JCP, suggesting that innate immune responses may contribute to this process. We previously reported that house dust mite directly activates the effector functions of eosinophils. Similar mechanisms may play roles in the JCP-related aggravation of allergic diseases.

Objective

To investigate whether JCP or Cry j 1, a major allergen of JCP, can modify the effector functions of eosinophils.

Methods

Eosinophils isolated from the peripheral blood of healthy donors were stimulated with either JCP or Cry j 1, and their adhesion to human intercellular adhesion molecule-1 was measured using eosinophil peroxidase assays. The generation of eosinophil superoxide anion (O₂⁻) was measured based on the superoxide dismutase-inhibitable reduction of cytochrome C. Concentrations of eosinophil-derived neurotoxin in the cell media were measured by enzyme-linked immunosorbent assay as a marker of degranulation.

Results

Both JCP and Cry j 1 directly induced eosinophil adhesiveness, generation of O₂⁻, and release of eosinophil-derived neurotoxin. Both anti-αM and anti-β2 integrin antibodies blocked all of these eosinophil functions induced by JCP and Cry j 1. Similarly, PAR-2 antagonists also partially suppressed all of these effector functions induced by JCP and Cry j 1.

Conclusion

JCP and Cry j 1 directly activate the functions of eosinophils, and both αMβ2 integrin and partly PAR-2 are contributed to this activation. Therefore, JCP-induced eosinophil activation may play a role in the aggravation of allergic airway diseases in nonsensitized patients as well as in JCP-sensitized patients.

B cells and upper airway disease: allergic rhinitis and chronic rhinosinusitis with nasal polyps evaluated

Introduction: The first mucosal site to encounter inhaled allergen, antigen, and microbes is the upper airway. It must perforce have a rapid system of environmental threat recognition and self-defense. B cells play a critical role in such airway host-defense, tissue surveillance, and immune modulation. Several common upper airway diseases can be defined in the expression of either exaggerated or dysregulated B-cell function within T2-high mucosal inflammatory states.Areas covered: In this review, the authors discuss the immunology of allergic rhinitis (AR) and chronic rhinosinusitis with nasal polyps (CRSwNP) in the context of highlighting key aspects of B-cell biology and function. The review is based on the findings of a literature search using the terms B cells, rhinitis, nasal polyps, and rhinosinusitis.Expert opinion: Despite the emerging role of B-cell overdrive and dysfunction in upper airway disease, studies are lacking specifics to B cells, particularly in association with sinonasal infection and mucosal inflammation. There is a pressing need to focus on how respiratory inflammation, alongside impaired or exaggerated B-cell function, amplifies and further dysregulates immune signaling pathways in the disease setting of AR and CRSwNP.

Biomarkers for diagnosis and prediction of therapy responses in allergic diseases and asthma

Modern health care requires a proactive and individualized response to diseases, combining precision diagnosis and personalized treatment. Accordingly, the approach to patients with allergic diseases encompasses novel developments in the area of personalized medicine, disease phenotyping and endotyping, and the development and application of reliable biomarkers. A detailed clinical history and physical examination followed by the detection of IgE immunoreactivity against specific allergens still represents the state of the art. However, nowadays, further emphasis focuses on the optimization of diagnostic and therapeutic standards and a large number of studies have been investigating the biomarkers of allergic diseases, including asthma, atopic dermatitis, allergic rhinitis, food allergy, urticaria and anaphylaxis. Various biomarkers have been developed by omics technologies, some of which lead to a better classification of distinct phenotypes or endotypes. The introduction of biologicals to clinical practice increases the need for biomarkers for patient selection, prediction of outcomes and monitoring, to allow for an adequate choice of the duration of these costly and long‐lasting therapies. Escalating healthcare costs together with questions about the efficacy of the current management of allergic diseases require further development of a biomarker‐driven approach. Here, we review biomarkers in diagnosis and treatment of asthma, atopic dermatitis, allergic rhinitis, viral infections, chronic rhinosinusitis, food allergy, drug hypersensitivity and allergen immunotherapy with a special emphasis on specific IgE, the microbiome and the epithelial barrier. In addition, EAACI guidelines on biologicals are discussed within the perspective of biomarkers.

The role of the nasal allergen provocation test in local allergic rhinitis cases: a preliminary report

INTRODUCTION

The current state of knowledge is that allergic rhinitis can occur in two forms. One is allergic rhinitis as a manifestation of a systemic allergy with systemic atopy and positive results of skin prick tests or sIgE tests. The other is local allergic rhinitis (LAR) as a local allergic reaction affecting only the nasal mucosa without systemic atopy.

AIM

To attempt to assess the usefulness of the nasal allergen provocation test for the purposes of differential diagnosis and the qualification of LAR patients for therapy.

MATERIAL AND METHODS

The subjects in the study were a group of 6 adults diagnosed with LAR on the basis of their medical history and the results of nasal allergen provocation tests, with the allergens being house dust mites (Dermatophagoides pteronyssinus, Dermatophagoides farinae). The methods adopted in the study were a point-based rating scale as a measure of nasal/extranasal complaints and active anterior rhinomanometry.

RESULTS

Significant differences (p < 0.05) were observed, using the subjective rating scale, in relation to registered nasal and extranasal complaints in the early phase of the allergic reaction. Similarly, the rhinomanometry method revealed significant differences in nasal resistance values before and after the administration of an allergen.

CONCLUSIONS

The nasal allergen provocation test is the only testing tool that objectively measures the degree of the patient's allergic reactions and is useful in qualifying LAR patients for further therapy.

[Th2 cells and macrophages induce novel type-I-hypersensitivity-like reaction]

In recent decades, many patients have been suffering from allergic rhinitis including Japanese cedar pollinosis, which is becoming a national disease in Japan. There is other upper airway intractable disease, called eosinophilic sinusitis. The elucidation of the pathogenesis of upper airway intractable disease is demanded for the development of novel therapies. Many researches about allergic pathogenesis have focused on IgE-mast cells pathway, however, there are the patients with allergic symptoms induced by non-IgE mediated mechanisms. The patients who show allergic rhinitis-like symptoms, such as sneezing, nasal discharge, and nasal clotting, without allergen-specific IgE, are diagnosed as non-allergic rhinitis. The precise mechanisms of non-allergic rhinitis are totally unclear. We have investigated the non-IgE mediated nasal symptoms, because the elucidation of non-IgE mediated mechanisms might lead to the elucidation of other upper airway intractable disease. We established antigen-specific Th2 cells transfer model and revealed the novel allergic mechanisms induced by Th2 cells, macrophages and endotoxin. Although Th2 cells play important roles in allergic diseases, the main function of Th2 cells are thought to produce Th2 cytokines, such as interleukin (IL)-4, IL-5, IL-13. We revealed the new functions of Th2 cells in allergic diseases. In addition, we found the novel histamine production mechanisms using in vitro macrophages and Th2 cells co-culture model. Both macrophages and Th2 cells produced histamine by the interaction through antigen. Our observations suggested the existence of the novel allergic mechanisms distinct from IgE-mast cells pathway.

Nasal IgE in subjects with allergic and non-allergic rhinitis

Purpose

The prevalence of "ocal allergic rhinitis" within individuals suffering from perennial rhinitis remains uncertain, and patients usually are diagnosed with non-allergic rhinitis. The aim of this study was to evaluate the prevalence of a potential "local allergic rhinitis" in subjects suffering from non-allergic rhinitis in a non-selected group of young students.

Methods

131 students (age 25.0 ± 5.1 years) with a possible allergic rhinitis and 25 non-allergic controls without rhinitis symptoms (age 22.0 ± 2.0 years) were recruited by public postings. 97 of 131 students with rhinitis were tested positive (≥3 mm) to prick testing with 17 frequent allergens at visit 1. Twenty-four 24 subjects with a house dust mite allergy, 21 subjects with a non-allergic rhinitis, and 18 non-allergic controls were further investigated at visit 2. Blood samples were taken, and nasal secretion was examined. In addition, all groups performed a nasal provocation test with house dust mite (HDM).

Results

In serum and nasal secretion, total IgE and house dust mite specific IgE significantly differed between HDM positive subjects and controls. However, no differences between non-allergic subjects and control subjects were quantifiable. Neither a nasal provocation test nor a nasal IgE to HDM allergens showed a measurable positive response in any of the non-allergic rhinitis subjects as well as the healthy controls, whilst being positive in 13 subjects with HDM allergy.

Conclusions

Nasal IgE is present in subjects with HDM allergy, but not in non-allergic rhinitis. In the investigated non-selected population, exclusive local production of IgE is absent. By implication, therefore, our findings challenge the emerging concept of local allergic rhinitis.Study identifier at ClinicalTrials.gov: NCT02810535.

The impact of allergies and smoking status on nasal mucosa of hypertrophied turbinates - an immunohistologic analysis

Background: Allergies and smoking are common reasons for nasal mucosa inflammations, which in turn, cause nasal obstructions. Nevertheless, the impact of coexisting allergies and smoking on nasal mucosa inflammation has not been studied.Objectives: To study the impact of smoking with relation to allergies on nasal mucosa histology and to characterize an immunologic profile using immunohistochemical (IHC) staining.Methods: A cross-sectional study. Nasal biopsies of inferior turbinates from smokers with different allergic statuses were compared. Demographics, comorbidities, histologic, and immunohistochemical (IHC) staining of CD3, CD68, CD 20, and CD138 receptors were compared and analyzed.Results: A total of 53 patients were included, of which 20 (37.7%) were smokers, and 20 (37.7%) had allergic backgrounds. Smokers, both allergic and non-allergic, demonstrated reduced edema compared to the control group (p Value = 0.034) and significantly lower eosinophil density in the stroma compared to the allergic nonsmokers' group (p Value = 0.04). Smokers had a significant negative correlation between the number of cigarettes per day and the expression of CD20 in the stroma (-0.452, p Value = 0.045) and the epithelium (-0.432, p Value = 0.057) in IHC staining. Allergic smokers had a negative correlation (-0.705, p Value = 0.023) between the number of cigarettes per day and the CD68 marked cell expression in the epithelium.Conclusion: The coexistence of an allergic background and smoking alters known immunologic responses within the nasal mucosa. Smoking may have an immunosuppressive role in the nasal mucosa in both innate and humoral immune systems.

Local Allergic Rhinitis Revisited

PURPOSE OF REVIEW

Local allergic rhinitis (LAR) represents a diagnostic and therapeutic challenge for clinicians. Even though it affects a considerable number of chronic rhinitis patients and a significant number of articles regarding prevalence, evolution, diagnosis, and treatment have been published, the condition remains still largely unrecognized and therefore misdiagnosed and mistreated.

RECENT FINDINGS

LAR is a unique form of chronic rhinitis; it is neither classical allergic rhinitis (AR) nor non-allergic rhinitis (NAR). The symptoms, duration, severity, and complications of LAR are similar to those of AR and can affect adults and children. Thus, a portion of patients diagnosed with NAR or chronic rhinitis of unknown etiology may have LAR. The relationship between LAR inflammation and systemic allergic inflammation is unclear. Patients are frequently misdiagnosed with idiopathic NAR, and distinguishing between both entities is difficult without specific diagnostic tests. Underdiagnosis of LAR has implications on the management of these patients, as they are deprived of allergen immunotherapy (AIT) that has been demonstrated to modulate the immune mechanisms underlying allergic diseases. This review aims to comprehensively summarize the current knowledge on LAR and address unmet needs in the areas of disease diagnosis and treatment.

Allergen Immunotherapy for Local Respiratory Allergy

PURPOSE OF REVIESW

Local respiratory allergy (LRA) is an eosinophilic phenotype of chronic airway disease. Three entities have been described within the LRA spectrum: local allergic rhinitis (LAR) and local allergic asthma (LAA) in non-atopic patients, and dual allergic rhinitis (DAR) in atopic patients (coexistence of LAR and allergic rhinitis). In this article, we aim to review the current evidence on the therapeutic options for LRA.

RECENT FINDINGS

No controlled study has assessed the effect of standard therapy (oral antihistamines, intranasal or inhaled corticosteroids, bronchodilators) in LRA subjects. Three randomized clinical trials and one observational study demonstrated that allergen immunotherapy (AIT) is able to control nasal and ocular symptoms, decrease the need for rescue medication, and improve quality of life in LAR individuals. Nasal or inhaled steroids can be expected to improve eosinophilic inflammation in LRA patients but cannot change the natural course of the disease. Moreover, the long-term and disease-modifying effects of AIT in LRA subjects need to be investigated.

[Diagnosis of allergy in asthma]

Allergy is a hypersensitivity reaction induced by immunological mechanisms. In asthma, allergy has a complex role and is usually IgE mediated. Allergy must be evaluated during the work up but evidence of IgE sensitivity does not mean that allergens play a role in the pathophysiology of the disease. The clinical relevance of the sensitivity has to be considered. This paper describes current available tools to screen for IgE sensitivity, allergen exposure and their role in asthma.

Reversal of Olfactory Disturbance in Allergic Rhinitis Related to OMP Suppression by Intranasal Budesonide Treatment

PURPOSE

We evaluated the severity of olfactory disturbance (OD) in the murine model of allergic rhinitis (AR) and local allergic rhinitis (LAR) in mice. We also investigated the therapeutic effect of an intranasal steroid on OD.

METHODS

Forty BALB/c mice were divided into 5 groups (n = 8 for each). The control group was sensitized intraperitoneally (i.p.) and challenged intranasally (i.n.) with saline. Mice in the AR group got i.p. and i.n. ovalbumin (OVA) administration for AR induction. The LAR group was challenged i.n. with 1% OVA for inducing local nasal allergic inflammation, without inducing the systemic allergy. The OD group got an i.p. methimazole administration (75 mg/kg) to induce total destruction of olfactory mucosa. Mice in the intranasal budesonide group received i.n. budesonide (12.8 μ per time, 30 minutes after the i.n. OVA challenge) while using OVA to cause systemic allergies. We conducted a buried-food pellet test to functionally assess the degree of OD in each group by measuring the time taken until finding hidden food. We evaluated the damage to olfactory epithelium using histopathologic evaluation and compared the degree of olfactory marker protein (OMP) expression in olfactory epithelium using immunofluorescent staining.

RESULTS

Mice of the AR (81.3 ± 19.8 seconds) and LAR groups (66.2 ± 12.7 seconds) spent significantly more time to detect the pellets than the control group (35.6 ± 12.2 seconds, P < 0.01). After treatment, the intranasal budesonide group exhibited significantly better results (35.8 ± 11.9 seconds) compared with the AR and LAR groups (P < 0.01). The AR and LAR groups showed considerable olfactory epithelial damage and suppression of OMP expression compared with the control group. In the intranasal budesonide group, the olfactory lesions and OMP expression had improved substantially.

CONCLUSIONS

OD may be caused by olfactory epithelial damage and suppression of OMP expression in nasal allergic inflammation and could be reversed using an intranasal steroid.

IgE repertoire and immunological memory: compartmental regulation and antibody function

It is now generally recognized that bone marrow is the survival niche for antigen-specific plasma cells with long-term immunological memory. These cells release antibodies into the circulation, needed to prime effector cells in the secondary immune response. These antibodies participate in the surveillance for antigen and afford immune defence against pathogens and toxins previously encountered in the primary immune response. IgE antibodies function together with their effector cells, mast cells, to exert 'immediate hypersensitivity' in mucosal tissues at the front line of immune defence. The constant supply of IgE antibodies from bone marrow plasma cells allows the rapid 'recall response' by mast cells upon re-exposure to antigen even after periods of antigen absence. The speed and sensitivity of the IgE recall response and potency of the effector cell functions are advantageous in the early detection and elimination of pathogens and toxins at the sites of attack. Local antigen provocation also stimulates de novo synthesis of IgE or its precursors of other isotypes that undergo IgE switching in the mucosa. This process, however, introduces a delay before mast cells can be sensitized and resume activity; this is terminated shortly after the antigen is eliminated. Recent results from adaptive immune receptor repertoire sequencing of immunoglobulin genes suggest that the mucosal IgE+ plasmablasts, which have undergone affinity maturation in the course of their evolution in vivo, are a source of long-lived IgE+ plasma cells in the bone marrow that are already fully functional.

How to Diagnose and Treat Local Allergic Rhinitis: A Challenge for Clinicians

Chronic rhinitis is a very common disease that can be divided in various phenotypes. Historically, the condition has been classified into the allergic rhinitis (AR) and non-allergic non-infectious rhinitis (NAR) forms, based on the results of the classical biomarkers of atopy: skin prick test and serum allergen-specific IgE However, this classification does not reflect the complexity of the rhinitis syndrome, as illustrated by the existence of non-atopic rhinitis patients who display a nasal reactivity to environmental allergens. This new phenotype has been termed local allergic rhinitis (LAR) and can be only recognized if an additional test such as the nasal allergen challenge (NAC) is integrated in the diagnostic algorithm for chronic rhinitis. Recent data shows that the NAC is a very safe and reliable technique ready for the clinical practice. LAR is a differentiated rhinitis phenotype which often commences during childhood and quickly progresses towards a clinical worsening and the association of comorbidities in other mucosal organs. Recent evidence supports the existence of a bronchial counterpart of LAR (local allergic asthma), which highlights the pathophysiological links between the upper and lower airways and reinforces the united airways concept. Importantly, several controlled studies have demonstrated the ability of allergen immunotherapy to control LAR symptoms while the therapy is being administered. This review emphasizes the need to implement the NAC in the clinical practice in order to facilitate the recognition of LAR patients, allowing for an early prescription of specific therapies with disease-modifying potential.

Nasal Cytology as a Diagnostic Tool for Local Allergic Rhinitis

Background

Local allergic rhinitis (LAR) is characterized by chronic rhinitis with localized nasal allergic response to allergens in the absence of systemic immunoglobulin (IgE)-mediated disease assessed by skin prick test (SPT) or specific serum IgE level. Nasal provocation test (NPT) is the gold standard for the diagnosis of LAR. Nasal eosinophilia is a known inflammatory marker in allergic rhinitis. We hypothesized that nasal eosinophilia can be used as a screening tool for LAR.

Objective

To determine the applicability of nasal eosinophilia as a diagnostic tool for LAR.

Methods

Forty-eight perennial nonallergic rhinitis (NAR) patients with SPT negative were recruited. Nasal cytology analysis was performed. NPTs with 3 allergens (mixed mites, mixed cockroaches, and Bermuda grass) were performed to diagnose LAR. Nasal symptoms combined with nasal patency were used to determine the results of NPT. The sensitivity, specificity, positive predictive value, and negative predictive value of nasal eosinophilia as a diagnostic tool of LAR were calculated.

Results

LAR was diagnosed in 41.6% of the NAR patients. Nasal eosinophilia was found in 58% of the NAR patients. The sensitivity of nasal eosinophilia for diagnosing LAR was 80%, the specificity was 57.14%, the positive predictive value was 57.14%, and the negative predictive value was 80%. The most common allergen of LAR was mixed mites.

Conclusion

Nasal eosinophilia on nasal cytology was a good screening tool for diagnosing LAR because of its high sensitivity and simplicity of the procedure. Unfortunately, the low specificity of nasal eosinophilia makes the NPT necessary for confirmation of LAR.

Local allergic conjunctivitis: a phenotype of allergic conjunctivitis

PURPOSE

Local allergic rhinitis (LAR) has been reported in the field of otolaryngology; however, the concept of local allergic conjunctivitis (LAC) has not been widely studied in the ophthalmologic community. We routinely examined total IgE levels in tear fluids (t-tIgE) and antigen-specific IgE levels in serum (s-sIgE) in patients with suspected allergic conjunctivitis, on the basis of Japanese guidelines for allergic conjunctival diseases. There are several cases in which the results of t-tIgE and s-sIgE testing are divergent. We suggest that these divergent cases correspond to LAR in otolaryngology.

METHODS

The study included 148 patients (33 men and 115 women) with clinical symptoms and signs of allergic conjunctivitis. Allerwatch Tear IgE^® was used for measurement of t-tIgE levels. ImmunoCAP Rapid^® and View Allergy 39^® were used for measurement of s-sIgE levels. Conjunctival cytology using spatula was used to identify eosinophils on the conjunctiva.

RESULTS

A total of 83 patients (56.1%) were positive and 65 patients were negative for t-tIgE in the AW. In the ICR, 97 patients (65.5%) were positive for at least one of the eight allergens, whereas 51 (34.5%) were negative for all allergens. Among 83 patients positive for t-tIgE, 14 (16.9%) had no detectable s-sIgE. Therefore, we considered the possibility of LAC in cases in which only local IgE could be detected. Among 28 cases (18.9%) who were negative for t-tIgE and s-sIgE, 21 underwent conjunctival scraping; eosinophils were found in four cases and eosinophilic granules in two. Accordingly, we considered the possibility of non-IgE-type AC in these six cases.

CONCLUSIONS

These results suggest the existence of LAC that is a candidate of a phenotype of AC.

Is the evidence of local allergic rhinitis growing?

PURPOSE OF REVIEW

To examine the recent advances on epidemiological studies, diagnostic approach and clinical management of local allergic rhinitis (LAR) in adults and children.

RECENT FINDINGS

Evidence about LAR is growing especially in pediatric and Asian populations. The prevalence of LAR is lower in Asian countries compared with western countries in both children and adults. LAR is considered a chronic condition and an independent rhinitis phenotype that affects up to 26.5% of nonatopic rhinitis patients. The disease rapidly progress toward the clinical worsening with associated onset of asthma and conjunctivitis, which further impairs patient's quality of life. Nasal Allergen Provocation Test is the diagnostic gold standard that can be complemented by basophil activation test and the detection of specific IgE in nasal secretions. Allergen immunotherapy induces a significant and early improvement in both clinical symptoms and quality of life in LAR patients.

SUMMARY

LAR is a common entity, with different prevalence depending on geographical locations. LAR has to be considered in the process of differential diagnosis in children and adults with rhinitis. Diagnosis of LAR is crucial in order to start an etiologic treatment such as allergen immunotherapy, which has proven to be very effective in these patients.

Effect of Prostaglandin E1 Analog Misoprostol in An Ovalbumin-Induced Allergic Rhinitis Model

Objective

The aim of the present study was to demonstrate the effects of misoprostol in ovalbumin-induced allergic rhinitis (AR). The second purpose was to compare the effect profile of the combination of an antihistamine with misoprostol during treatment of AR.

Materials and Methods

Twenty-five adult male rats were used and were randomly classified into five groups (n=5): healthy+saline, AR, AR and desloratadine (D)-treated group, AR and misoprostol (M)-treated group, and AR and combined-treated group.

Results

Desloratadine administration had significantly lower nasal symptoms than the AR group, but nasal symptoms in the AR+M group were better than those in the AR+D group. The best improvement in serum IgE levels was seen in the misoprostol alone and combination treatment groups.

Conclusion

We suggest that prostaglandins should be considered in the treatment of AR, and that the effects of these types of drugs should be tested clinically in patients.

Dermatophagoides farinae Upregulates the Effector Functions of Eosinophils through αMβ2-Integrin and Protease-Activated Receptor-2

BACKGROUND

Even in subjects who are not sensitized to house dust mite (HDM), allergic symptoms can be aggravated by exposure to dust, suggesting that innate immune responses may be involved in these processes. Since eosinophils express pattern recognition receptors, HDM may directly upregulate eosinophil functions through these re ceptors. The objective of this study was to examine whether Dermatophagoides farinae (Df), a representative HDM, or Der f 1, a major allergen of Df, modifies the effector functions of eosinophils.

METHODS

Eosinophils isolated from the blood of healthy donors or allergic patients were stimulated with Df extract or Der f 1, and their adhesion to recombinant human intercellular adhesion molecule (ICAM)-1 was measured using eosinophil peroxidase assays. Generation of the eosinophil superoxide anion (O2-) was examined based on the superoxide dismutase-inhibitable reduction of cytochrome C. Eosinophil-derived neurotoxin (EDN) concentrations in cell media were measured by ELISA as a marker of degranulation.

RESULTS

Df extract or Der f 1 directly induced eosinophil adhesion to ICAM-1, O2- generation, and EDN release. Anti-αM- or anti-β2-integrin antibodies or protease-activated receptor (PAR)-2 antagonists suppressed the eosinophil adhesion, O2- generation, and EDN release induced by Df extract or Der f 1. Eosinophils from allergic patients showed higher adhesion to ICAM-1 than those from healthy donors.

CONCLUSIONS

These findings suggested that Df extract and Der f 1 directly activate eosinophil functions through αMβ2-integrin and PAR-2. Eosinophil activation by HDM may play roles in the aggravation of allergic symptoms, not only in HDM-sensitized patients, but also in nonsensitized patients.

Allergic rhinitis

Allergic rhinitis is a common disorder that is strongly linked to asthma and conjunctivitis. It is usually a long-standing condition that often goes undetected in the primary-care setting. The classic symptoms of the disorder are nasal congestion, nasal itch, rhinorrhea and sneezing. A thorough history, physical examination and allergen skin testing are important for establishing the diagnosis of allergic rhinitis. Second-generation oral antihistamines and intranasal corticosteroids are the mainstay of treatment. Allergen immunotherapy is an effective immune-modulating treatment that should be recommended if pharmacologic therapy for allergic rhinitis is not effective or is not tolerated, or if chosen by the patient. This article provides an overview of the pathophysiology, diagnosis, and appropriate management of this disorder.

[The usefulness of nasal provocation tests for respiratory physicians]

Rhinitis and asthma are common diseases that are strongly linked from both the epidemiological and patho-physiological point of view. A precise aetiological diagnosis is required in order to optimize treatment. Nasal provocation tests (NPT) determine precisely the role of the allergen in the initiation of the symptoms of rhinitis particularly when the history does not produce convincing evidence of the clinical relevance of an allergen. It may also have important consequences for the choice of an allergenic immunotherapy. NPT are not standardized but simple methods based on international recommendations provide us with good diagnostic accuracy. In this paper, we will discuss the practical aspects of NPT as well as the clinical or research situations where they may be useful for the respiratory physician.

Nasal cytology: Methodology with application to clinical practice and research

Nasal cytology is an easy, cheap, non-invasive and point-of-care method to assess nasal inflammation and disease-specific cellular features. By means of nasal cytology, it is possible to distinguish between different inflammatory patterns that are typically associated with specific diseases (ie, allergic and non-allergic rhinitis). Its use is particularly relevant when other clinical information, such as signs, symptoms, time-course and allergic sensitizations, is not enough to recognize which of the different rhinitis phenotypes is involved; for example, it is only by means of nasal cytology that it is possible to distinguish, among the non-allergic rhinitis, those characterized by eosinophilic (NARES), mast cellular (NARMA), mixed eosinophilic-mast cellular (NARESMA) or neutrophilic (NARNE) inflammation. Despite its clinical usefulness, cheapness, non-invasiveness and easiness, nasal cytology is still underused and this is at least partially due to the fact that, as far as now, there is not a consensus or an official recommendation on its methodological issues. We here review the scientific literature about nasal cytology, giving recommendations on how to perform and interpret nasal cytology.

Local allergic rhinitis: Implications for management

A significant proportion of rhinitis patients without systemic IgE-sensitisation tested by skin prick test and serum allergen-specific IgE (sIgE) display nasal reactivity upon nasal allergen provocation test (NAPT). This disease phenotype has been termed local allergic rhinitis (LAR). LAR is an underdiagnosed entity affecting children and adults from different parts of the world, with moderate-to-severe symptoms, impairment of quality of life and rapid progression to symptom worsening. LAR is a stable phenotype and not merely an initial state of AR. Allergic rhinitis and LAR share many clinical features including a positive NAPT response, markers of type 2 nasal inflammation including sIgE in nasal secretions and a significant rate of asthma development. LAR should be considered as a differential diagnosis in those subjects of any age with symptoms suggestive of AR but no evidence of systemic atopy. Although LAR pathophysiology is partially unknown, in some patients sIgE can be demonstrated directly in the nasal secretions and/or indirectly via positive responses in basophil activation test (BAT). LAR can coexist with other rhinitis phenotypes, especially AR. The diagnosis currently relies on the positivity of NAPT to a single or multiple allergens. NAPT has high sensitivity, specificity and reproducibility, and it is considered the gold standard. BAT and the measurement of nasal sIgE can also contribute to LAR diagnosis. LAR patients benefit from the same therapeutic strategies than AR individuals, including the avoidance of allergen exposure and the pharmacotherapy. Moreover, several recent studies support the effectiveness and safety of allergen immunotherapy for LAR, which opens a window of treatment opportunity in these patients.

Physician-diagnosed eczema is an independent risk factor for incident mouse skin test sensitization in adults

BACKGROUND

The disrupted skin barrier in eczema has been associated with an increased risk of immunoglobulin E (IgE) sensitization in childhood. However, it is unclear whether eczema, independent of atopy, is a risk factor for the development of allergic sensitization in adulthood.

OBJECTIVE

To determine if skin barrier dysfunction, independent of atopy, is a risk factor for incident sensitization in adult workers at a mouse production and research facility.

METHODS

New employees at The Jackson Laboratory enrolled in a cohort study and underwent skin-prick testing (SPT) at baseline and every 6 months to mouse and to a panel of aeroallergens (net wheal ≥3 mm indicated a positive SPT result). Mouse allergen exposure was measured every 6 months by using personal air monitors. Physician-diagnosed eczema was defined as self-reported physician-diagnosed eczema. Cox proportional hazard modeling was used to examine the association between baseline physician-diagnosed eczema and incident mouse skin test sensitization and adjusted for potential confounders.

RESULTS

The participants (N = 394) were followed up for a median of 24 months. Fifty-four percent were women, 89% were white, and 64% handled mice. At baseline, 7% of the participants reported physician-diagnosed eczema and 9% reported current asthma; 61% had at least one positive skin test result. At 30 months, 36% of those with eczema versus 14% of those without eczema had developed a positive mouse skin test result (p = 0.02, log-rank test). After adjusting for age, race, sex, smoking status (current, former, never), current asthma, hay fever, the number of positive SPT results at baseline, and mouse allergen exposure, physician-diagnosed eczema was an independent risk factor for incident mouse SPT sensitization (hazard ratio 5.6 [95% confidence interval, 2.1-15.2]; p = 0.001).

CONCLUSION

Among adult workers at a mouse production and research facility, physician-diagnosed eczema was a risk factor for incident mouse sensitization, independent of atopy, which indicated that a defect in skin barrier alone may increase the risk of skin sensitization, not just in childhood, but throughout life.

Responsiveness of Nasal Provocation Testing-But Not Skin Test and Specific Immunoglobulin E Blood Level-Correlates With Severity of Allergic Rhinitis in Dermatophagoides Species-Sensitized Patients

Background The results of skin and blood allergen testing are not consistently relevant to clinical manifestations in allergic patients. Objective The aim of the study was to investigate the relationship between severity of allergic rhinitis and different allergen diagnostic tests in Dermatophagoides species-sensitized patients. Methods Study subjects included 65 rhinitis patients-50 with Dermatophagoides pteronyssinus (DP) sensitization (DP+) and 15 without DP sensitization (DP-), and 15 DP+ and 37 DP- healthy controls (HCs) confirmed by allergen skin prick (SPT) and blood specific immunoglobulin E (sIgE) tests. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was tested. All subjects underwent DP nasal provocation test (DP-NPT). Visual analogue scoring (VAS) of nasal symptoms and nasal airway resistance (NAR) were measured before and after NPT. Correlations between the 3 allergen tests and score of RQLQ were performed. Results All rhinitis subjects had significantly higher VAS and NAR after DP-NPT than HCs ( P < .01). All DP+ rhinitis, 40% of DP- rhinitis subjects, 13.3% of DP+ HCs and 0% of DP- HCs had positive DP-NPT. Dose of positive DP-NPT positively correlated with SPT diameter and sIgE level in all tested subjects ( P < .001). Score of RQLQ positively correlated with dose of DP-NPT ( P < .001), but not with SPT diameter and sIgE level in rhinitis patients. Conclusion Although DP nasal provocation, skin prick wheal size and blood sIgE level correlate with each other, only nasal provocation testing is associated with severity of nasal symptoms. It is suggested that NPT should be performed to verify a clinically relevant allergy.

Specific immunotherapy in local allergic rhinitis: A randomized, double-blind placebo-controlled trial with Phleum pratense subcutaneous allergen immunotherapy

BACKGROUND

Allergen immunotherapy has been shown to be an effective treatment for local allergic rhinitis (LAR) to house dust mites. Studies with pollen allergen immunotherapy are limited to observational studies. The aim of this study was to evaluate the clinical efficacy and safety of Phleum pratense subcutaneous immunotherapy (Phl-SCIT) in LAR.

METHODS

In a randomized double-blind placebo-controlled study, 56 patients with moderate-severe LAR to grass pollen received Phl-SCIT with a depigmented polymerized pollen vaccine or placebo for the first year, and Phl-SCIT the second one. The blind was maintained throughout the study. Primary outcome was combined symptom medication score (CSMS) during grass pollen season (GPS). Secondary clinical outcomes included organ-specific symptoms, medication-free days, rhinitis severity and asthma control. Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), nasal allergen provocation test (NAPT), skin testing, serum levels of specific IgG4 and specific IgE and safety were also evaluated.

RESULTS

Subcutaneous immunotherapy (SCIT) had a short-term and sustained effect with significant improvements of all primary and secondary clinical outcomes and RQLQ score. SCIT significantly increased serum sIgG4 levels and allergen tolerance, from the 6th to 24th months of treatment. At the end of the study, 83% of patients treated with ≥6 months of SCIT tolerated a concentration of P. pratense over 50 times higher than baseline, and 56% gave a negative NAPT. SCIT was well tolerated; six mild local reactions occurred, and there were no serious adverse events related to the study medication.

CONCLUSIONS

Subcutaneous immunotherapy with depigmented polymerized allergen extracts is a safe and clinically effective treatment for LAR to P. pratense.

EAACI Guidelines on Allergen Immunotherapy: Allergic rhinoconjunctivitis

Allergic rhinoconjunctivitis (AR) is an allergic disorder of the nose and eyes affecting about a fifth of the general population. Symptoms of AR can be controlled with allergen avoidance measures and pharmacotherapy. However, many patients continue to have ongoing symptoms and an impaired quality of life; pharmacotherapy may also induce some side-effects. Allergen immunotherapy (AIT) represents the only currently available treatment that targets the underlying pathophysiology, and it may have a disease-modifying effect. Either the subcutaneous (SCIT) or sublingual (SLIT) routes may be used. This Guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on AIT for AR and is part of the EAACI presidential project "EAACI Guidelines on Allergen Immunotherapy." It aims to provide evidence-based clinical recommendations and has been informed by a formal systematic review and meta-analysis. Its generation has followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included involvement of the full range of stakeholders. In general, broad evidence for the clinical efficacy of AIT for AR exists but a product-specific evaluation of evidence is recommended. In general, SCIT and SLIT are recommended for both seasonal and perennial AR for its short-term benefit. The strongest evidence for long-term benefit is documented for grass AIT (especially for the grass tablets) where long-term benefit is seen. To achieve long-term efficacy, it is recommended that a minimum of 3 years of therapy is used. Many gaps in the evidence base exist, particularly around long-term benefit and use in children.

Sentinels of the Type 2 Immune Response

Type 2 immune responses have evolved to sense and respond to large, non-replicating infections or non-microbial noxious compounds in tissues. The development of these responses therefore depends upon highly coordinated and tightly regulated tissue-residing cellular sensors and responders. Multiple exposure to type 2 helper T cell (Th2)-inducing stimuli further enhances both the diversity and potency of the response. This review discusses advances in our understanding of the interacting cellular subsets that comprise both primary and secondary type 2 responses. Current knowledge regarding type 2 immune responses in the lung are initially presented and are then contrasted with what is known about the small intestine. The studies described portray an immune response that depends upon well-organized tissue structures, and suggest their modulation as a therapeutic strategy.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Clinical Evaluation of Techniques for Measuring Nasal-Specific Immunoglobulin E in Pediatric Patients

Currently used methods for collecting nasal-specific immunoglobulin E (IgE) require administration of a large amount of saline into the nostrils, which is difficult in children. We designed two methods that are easy to use in children. We measured nasal-specific IgE and evaluated clinical characteristics of nasal-specific IgE in pediatric rhinitis. This study included 82 patients who visited Kyungpook National University Children's Hospital from December 2014 to July 2016 with rhinitis symptoms. Thirty patients used the spray method, and 52 patients used the swab method. We examined nasal-specific IgE to Dermatophagoides farinae, Dermatophagoides pteronyssinus, Alternaria, birch, and weed mix. Thirty patients had nasal-specific IgE concentrations of ≥ 0.35 kIU/L. There was a positive correlation between nasal-specific IgE and serum-specific IgE to D. farinae and D. pteronyssinus (r = 0.548, P < 0.001; r = 0.656, P < 0.001). If we regard positivity of skin prick test as standard, cutoff point of nasal-specific IgE to D. farinae was 0.11 kIU/L and to D. pteronyssinus was 0.12 kIU/L. Based on these cutoff points, five patients would be considered to have local allergic rhinitis. The methods showed relatively high positivity for nasal-specific IgE, which reflected the serum-specific IgE as well. These methods can be considered to diagnose local allergic rhinitis in children.

Local Allergic Rhinitis in Pediatric Patients: Is IgE Dosage in Nasal Lavage Fluid a Useful Diagnostic Method in Children?

Local Allergic Rhinitis (LAR) is an emerging disease. However, its incidence in the pediatric popolution has not yet been studied. The gold standard for the diagnosis is the nasal provocation test that is not everywhere avalaible and difficult to apply in children. The aim of our study was to evaluate the nasal lavage fluid IgE as a biomarker of LAR in children. 54 pediatric patients [IQR 4.0-12.0 years] were divided into 3 groups: study group (26 children with rhinitis symptoms and without evidence of systemic atopy); allergic rhinitis (AR) group (15 children) and 13 healty controls (HC). Every child was subjected to nasal lavage using 2 ml/nostril of physiologic saline solution, that was therefore analyzed by ImmunoCAP to obtain the IgE concentration. Rhinofibroscopy and nasal cytology were performed. Our data showed the presence of higher value of nasal lavage fluid IgE (average of 6.005 UI/ml; range: 4.47-7.74 UI/ml) in 16 out of 26 patients of the study group who therefore may be classified as affected by LAR. We observed a statistically significant difference (P< 0.0001) between NAR/HC group and LAR group, identifying a cut-off of 3.85 UI/ml. Finally, we found a better response to previous AR therapy in the LAR group than in the NAR group. Our data showed the high incidence of LAR in pediatric patients previously classified as NAR. The measurment of IgE in nasal lavage fluid may be considered an easy and rapid method for the diagnosis of LAR in children. Besides, our data add confirmatory evidence about the good response of LAR children to the classic AR therapy.

Emerging roles of basophils in allergic inflammation

Basophils have long been neglected in immunological studies because they were regarded as only minor relatives of mast cells. However, recent advances in analytical tools for basophils have clarified the non-redundant roles of basophils in allergic inflammation. Basophils play crucial roles in both IgE-dependent and -independent allergic inflammation, through their migration to the site of inflammation and secretion of various mediators, including cytokines, chemokines, and proteases. Basophils are known to produce large amounts of IL-4 in response to various stimuli. Basophil-derived IL-4 has recently been shown to play versatile roles in allergic inflammation by acting on various cell types, including macrophages, innate lymphoid cells, fibroblasts, and endothelial cells. Basophil-derived serine proteases are also crucial for the aggravation of allergic inflammation. Moreover, recent reports suggest the roles of basophils in modulating adaptive immune responses, particularly in the induction of Th2 differentiation and enhancement of humoral memory responses. In this review, we will discuss recent advances in understanding the roles of basophils in allergic inflammation.

The role of local allergy in the nasal inflammation

Local allergic inflammation (LAI) is recognized recently. 'entopy' was used to define LAI, which was positively correlated with allergen provocation testing, local sIgE up-regulation, inflammatory mediator secretion, and a lack of systemic allergy. The study of LAI is in its infancy and focuses mainly on the respiratory system. It is closely related to nasal inflammation and plays important roles in patients with nonallergic rhinitis (NAR), nonallergic chronic sinusitis with nasal polyps (CRSwNP), and nonallergic fungal rhinosinusitis (NAFRS). Based on studies using nasal allergen provocation testing, 40-57% of patients with NAR exhibited positive results and could be diagnosed as local allergic rhinitis. Total IgE and common airborne allergen-sIgE were up-regulated in eosinophilic CRSwNP patients compared to noneosinophilic CRSwNP patients and healthy controls, possibly due to local allergic inflammation. Some researchers also found that the level of local sIgE was increased in patients with NAFRS; they suggested that local allergic inflammation occurs in NAFRS. Studies of LAI will increase our understanding of nasal inflammation and help to establish novel treatments. However, the diagnosis of local allergic inflammation is complex due to the lack of convenient detection methods. The relationship between local allergic inflammation and systemic allergic inflammation is unclear, and an appropriate treatment for local allergic inflammation is required.

Pilot study of mobile phone technology in allergic rhinitis in European countries: the MASK-rhinitis study

BACKGROUND

The use of Apps running on smartphones and tablets profoundly affects medicine. The MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) App (Allergy Diary) assesses allergic rhinitis symptoms, disease control and impact on patients' lives. It is freely available in 20 countries (iOS and Android platforms).

AIMS

To assess in a pilot study whether (i) Allergy Diary users were able to properly provide baseline characteristics (ii) simple phenotypic characteristics based upon data captured by the Allergy Diary could be identified and (iii) information gathered by this study could suggest novel research questions.

METHODS

The Allergy Diary users were classified into six groups according to the baseline data that they entered into the App: (i) asymptomatic; (ii) nasal symptoms excluding rhinorrhea; (iii) rhinorrhea; (iv) rhinorrhea plus 1-2 nasal/ocular symptoms; (v) rhinorrhea plus ≥3 nasal/ocular symptoms; and (vi) rhinorrhea plus all nasal/ocular symptoms.

RESULTS

By 1 June 2016, 3260 users had registered with the Allergy Diary and 2710 had completed the baseline questionnaire. Troublesome symptoms were found mainly in the users with the most symptoms. Around 50% of users with troublesome rhinitis and/or ocular symptoms suffered work impairment. Sleep was impaired by troublesome symptoms and nasal obstruction.

CONCLUSIONS

This is the first App (iOS and Android) to have tested for allergic rhinitis and conjunctivitis. A simple questionnaire administered by cell phones enables the identification of phenotypic differences between a priori defined rhinitis groups. The results suggest novel concepts and research questions in allergic rhinitis that may not be identified using classical methods.