Recruitment of CD1a+ Langerhans cells to the nasal mucosa in seasonal allergic rhinitis and effects of topical corticosteroid therapy

BACKGROUND

Local antigen presentation may be necessary for both primary and recall T-cell responses to grass pollen in hay fever patients. We examined the effect of seasonal allergen exposure on nasal mucosal antigen-presenting cell (APC) populations and the effects of topical corticosteroid therapy.

METHODS

Nasal biopsies were collected from 46 grass pollen-sensitive seasonal rhinitis patients before the grass-pollen season. A second biopsy was collected during the pollen season, when patients had received 6 weeks' treatment with either fluticasone propionate (200 microg, twice daily) or placebo. Cell populations in biopsy sections were quantified by immunocytochemistry.

RESULTS

Significant increases in submucosal and epithelial CD1a+ Langerhans cells, but not CD68 + macrophages or CD20 + B cells, were observed during the pollen season. Seasonal increases in CD1a+ Langerhans cells were inhibited by corticosteroid therapy.

CONCLUSIONS

Recruitment of CD1a+ Langerhans cells to the nasal mucosa during natural seasonal allergen exposure may contribute to local T cell responses. Topical corticosteroids may act, at least in part, by inhibiting effective allergen presentation to T cells through inhibition of recruitment of Langerhans cells to the nasal mucosa.

Exercise-induced laryngochalasia: an imitator of exercise-induced bronchospasm

BACKGROUND

Patients with exercise-induced laryngochalasia present with dyspnea and stridor during exercise. Symptoms are due to a subtotal occlusion of the larynx resulting from mucosal edema from the aryepiglottic folds being drawn into the endolarynx.

METHODS

We report on three patients with exercise-induced bronchospasm, refractory to standard therapy.

RESULTS

Spirometry with flow-volume loops revealed truncation of the inspiratory limb. Abnormal movement of the arytenoid region was visualized on laryngoscopy. A diagnosis of exercise-induced laryngochalasia was made.

CONCLUSIONS

Evaluation of laryngeal motion in patients with refractory exercise-induced bronchospasm is important. Surgical correction with laser laryngoplasty is effective in carefully selected cases.

Improving readability of patient education materials

Functional illiteracy contributes to negative long-term health consequences for patients who must understand and adhere to complex health care instructions and, therefore, is of primary importance to community health nurses. This problem is compounded when English is the patient's second language. A process for improving patient education materials (PEMs) through adaptation or creation of new materials to meet the health needs of diverse groups is presented. The process was applied to a popular health education program used with school-age children and their parents to teach them home management of asthma. Target parents were known to read at a 5th-grade level, and English was a second language for many of them. Therefore, extensive revision of the existing PEMs was required. The steps to successful revision included assessing readability and comprehensibility, editing the materials, and evaluating the new PEMs to determine the effectiveness of the revision measures.

Effect of topical corticosteroids on seasonal increases in epithelial eosinophils and mast cells in allergic rhinitis: a comparison of nasal brush and biopsy methods

BACKGROUND

Nasal brushing and nasal biopsy are well-tolerated sampling techniques. Seasonal grass pollen-induced rhinitis is characterized by epithelial mast cell infiltration and seasonal increases in both epithelial and sub-mucosal eosinophils.

OBJECTIVE

To compare the ability of the nasal brush and nasal biopsy techniques to detect natural seasonal increases in eosinophils and mast cells, and to assess the influence of topical corticosteroid.

METHODS

Nasal brush samples and nasal biopsies were collected from 46 grass pollen-sensitive seasonal rhinitis patients before the grass pollen season and at the peak of the pollen season following 6 weeks' treatment with either fluticasone propionate aqueous nasal spray (200 microg, twice daily) or placebo nasal spray.

RESULTS

Placebo patients showed seasonal increases in epithelial eosinophils both with nasal brushing (P < 0.0001) and biopsy (P < 0.001). Epithelial mast cell numbers also increased during the pollen season as detectable by brushing (P < 0.0001) and biopsy (P < 0.03). Changes in cell numbers measured by nasal brushing correlated with those observed with nasal biopsy, both for eosinophils and mast cells (P < 0.05). Sub-mucosal eosinophils but not mast cells also increased during the pollen season (P < 0.002). Nasal brushing and biopsy revealed that fluticasone treatment inhibited seasonal increases in epithelial eosinophils (P < 0.00001) and epithelial infiltration by mast cells (nasal brushing P < 0.00001 and nasal biopsy P < 0.01). Fluticasone also inhibited seasonal increases in sub-mucosal eosinophils (P < 0.001) and significantly reduced nasal symptoms (P < 0.001).

CONCLUSION

Nasal brushing harvests sufficient inflammatory cells from the surface of the nasal mucosa to be used in lieu of nasal biopsies in observation of the effect of drugs on the nasal epithelium.

Nasal eosinophilia and IL-5 mRNA expression in seasonal allergic rhinitis induced by natural allergen exposure: effect of topical corticosteroids

BACKGROUND

Nasal allergen provocation in patients with allergic rhinitis leads to expression of the proeosinophilic cytokines IL-5 and GM-CSF and tissue eosinophilia.

OBJECTIVE

We sought to examine the effect of natural seasonal allergen exposure on IL-5 and GM-CSF mRNA expression and nasal eosinophilia and to evaluate the effects of topical corticosteroid therapy on these responses.

METHODS

Nasal biopsy specimens were collected from 46 grass pollen-sensitive patients with seasonal rhinitis before the grass pollen season. A second biopsy specimen was collected during the pollen season, by which time patients had received 6 weeks treatment with either fluticasone propionate (200 micro(g) twice daily) or placebo nasal spray.

RESULTS

Fluticasone treatment was clinically effective (P <.005). Patients receiving placebo, but not fluticasone, showed increased numbers of epithelial and submucosal EG2+ eosinophils (P <.005) and IL-5 and GM-CSF mRNA-expressing cells (P <.0001) during the pollen season. Colocalization experiments showed that greater than 80% of IL-5 mRNA-expressing cells were submucosal CD3+ T cells in both groups. The numbers of submucosal CD3+ T cells did not increase during the pollen season or decrease with fluticasone treatment. Fluticasone also inhibited IL-5 secretion by grass pollen-stimulated peripheral blood T cells from patients with seasonal rhinitis (n = 5, inhibitory concentration of 50% = 10(-9) to 10(-10) mol/L).

CONCLUSIONS

These results suggest that topical corticosteroids may reduce eosinophilia in seasonal rhinitis by inhibiting T cell IL-5 production.

Expression of IL-4, Cepsilon RNA, and Iepsilon RNA in the nasal mucosa of patients with seasonal rhinitis: effect of topical corticosteroids

BACKGROUND

Nasal allergen provocation has demonstrated that allergen-induced rhinitis is associated with an increase in local IL-4 mRNA and IgE heavy chain (Cepsilon) and IgE heavy chain promoter (Iepsilon) RNA and that pretreatment with topical glucocorticosteroids inhibits the increase in these transcripts.

OBJECTIVE

This study was undertaken to determine whether observations made after acute allergen provocation can be extended to the case of chronic exposure experienced during the pollen season.

METHODS

Biopsy specimens were obtained from the inferior turbinate of 33 pollen-sensitive subjects with allergic rhinitis before and during pollen season. Patients were randomized in a double-blind fashion and treated with either topical steroids (200 microg fluticasone propionate twice daily; n = 16) or matched placebo nasal spray (n = 17) before the pollen season. Alkaline phosphatase anti-alkaline phosphatase immunocytochemistry was used to identify B cells (CD20+), and in situ hybridization was used to detect IL-4, Cepsilon, and Iepsilon RNA+ cells.

RESULTS

Baseline examination revealed IL-4 and Cepsilon RNA but virtually no Iepsilon RNA+ cells in the nasal mucosa. Analysis revealed a significant difference in the expression of Cepsilon and Iepsilon RNA+ cells (p < 0.001). Biopsy specimens taken after antigen exposure exhibited highly significant increases in placebo-treated (p < 0.001) but not steroid-treated patients. In both groups, the number of CD20+ cells was unchanged when preexposure and postexposure biopsy specimens were compared.

CONCLUSIONS

These results show strong support for the hypothesis that IgE class switching occurs locally within the nasal mucosa of subjects with seasonal allergic rhinitis and that this response can be inhibited through strategies directed against local IgE production.

Fluticasone propionate aqueous nasal spray in the treatment of nasal polyposis

BACKGROUND

Topical glucocorticoids are the medical treatment of choice in a majority of patients suffering from nasal polyposis. Fluticasone propionate is a fluorinated steroid reported to be highly effective when used topically in the nose for seasonal and perennial allergic and nonallergic rhinitis.

OBJECTIVES

To evaluate the efficacy and tolerability of intranasal fluticasone propionate in the treatment of long-standing polyposis.

METHODS

Fifty-five patients with long-standing nasal polyposis were treated over a 26-week period with fluticasone propionate aqueous nasal spray 200 micrograms bid, beclomethasone dipropionate aqueous nasal spray 200 micrograms bid or placebo, administered intranasally in an aqueous spray in a double-blind, placebo-controlled parallel-group design at a single center. The primary efficacy endpoint was the physicians' assessment of symptoms and polyp score. Peak nasal inspiratory flow was performed twice daily and on every visit to evaluate the effect of the corticosteroids on nasal air flow.

RESULTS

A significant difference in the primary efficacy endpoint between fluticasone propionate aqueous nasal spray and beclomethasone dipropionate aqueous nasal spray compared with placebo was seen after 14 weeks of treatment. This was further verified by the peak nasal inspiratory flow results. There was some evidence of earlier onset in the fluticasone propionate aqueous nasal spray group compared with the beclomethasone dipropionate aqueous nasal spray group after 4 weeks in terms of the primary efficacy endpoint. From the daily record cards patients receiving fluticasone propionate aqueous nasal spray had a significantly higher percentage of days on which they required no rescue medication (P < .009) and a higher percentage of days with an overall nasal blockage score on waking of < 2 (P < .013) when compared with placebo-treated patients. No other statistically significant results were found between the two active compounds.

CONCLUSION

Fluticasone propionate aqueous nasal spray 200 micrograms bid and beclomethasone dipropionate aqueous nasal spray 200 micrograms bid are effective in treating the symptoms of nasal polyps, with some evidence that fluticasone propionate aqueous nasal spray has a faster onset of action and is tolerated at least as well as beclomethasone dipropionate aqueous nasal spray at the same dose.

Effect of systemically administered H1- and H2-receptor antagonists on nasal blood flow as measured with laser Doppler flowmetry in a provoked allergic reaction

Twelve subjects with seasonal allergic rhinitis were challenged topically with birch pollen extract in a double-blind, double-dummy, placebo-controlled, randomized cross-over study. Pre-treatment was performed with either a selective histamine-1 (H1-) antagonist (terfenadine), a selective H2-antagonist (cimetidine), a combination of these drugs or a placebo. Nasal mucosa microcirculatory blood flow was measured with the use of laser Doppler flowmetry. The allergen challenge induced a decrease in the microcirculatory blood flow of the nasal mucosa. Pre-treatment with the H1-antagonist inhibited this effect and allergic symptoms, while pre-treatment with the H2-antagonist did not. No signs of an additive effect were seen after combination of the antagonists. Thus, H1-receptors but not H2-receptors, seem to be of importance in the pathophysiology of the allergic rhinitis.

Proteinase content of mast cells of nasal mucosa; effects of natural allergen exposure and of local corticosteroid treatment

The distribution and density of metachromatic cells (MCC) and mast cells containing chymase plus tryptase (MCTC) or tryptase alone (MCT) were studied in the nasal mucosa by dye-binding methods and immunohistochemical analysis. Biopsies were obtained from 17 subjects with birch pollen allergy before and during the peak season and from nine healthy controls. Six patients were treated with an intranasal glucocorticosteroid before and during the season in an open study. Hay fever patients, even when asymptomatic, showed signs of mast cell system activation, exhibiting an increased number of mast cells in the nasal epithelium. Basophils, lacking immunohistochemically detectable tryptase, were not a major component of the mast cell response. MCT, most conspicuous in the epithelium, were found to be the most frequent mast-cell type in the nasal mucosa of allergic, but not of normal, subjects. Only 33% of the epithelial, but 90% of the stromal, immunopositive cells in the atopic mucosa before as well as during the season were MCC. Intraepithelial MCT thus displayed a low capacity to stain metachromatically, indicating a relative deficiency of the glycosaminoglycan (heparin) component of the granules. Intraepithelial mast cells also appeared to be markedly sensitive to steroid treatment and aldehyde fixation. The findings suggest that the lack of chymase, the characteristic feature of MCT, may reflect a functional activation of the mast cells, rather than a stable phenotypic differentiation related to anatomic site.

Cytofluorometric quantification of IgE and IgE receptors on individual mast cells

Information about the IgE receptor and IgE content of mast cells under different conditions in vivo is essential for further understanding the functions of the mast cell-IgE system. A cytofluorometric method for measuring cell-bound IgE on individual mast cells was therefore explored using peritoneal mast cells of Sprague-Dawley rats infected with the nematode N. brasiliensis and rat basophilic leukaemia cells (RBL-1) as experimental models. We systematically studied the effects of variables such as fixation, incubation time, temperature and concentrations of antibody on the fluorescence emission of the mast cells. Optimum conditions were selected for the quantitative measurement of IgE at the single-cell level using direct labelling with FITC-conjugated goat anti-rat IgE(Fc). Polystyrene beads with a defined fluorophor content and a fluorescent uranyl glass were used to standardise the measurement procedure. A linear relationship between fluorescence intensity and IgE concentration was obtained by fluorescence measurements on RBL-1 cells incubated in rat IgE. In the case of rat peritoneal mast cells it was possible to saturate the IgE receptors by incubating the mast cells in rat IgE. By measuring the mast cells before and after IgE incubation, the relative content of IgE, the relative number of IgE receptors and the degree of receptor saturation could be estimated. In this way we measured the IgE content of peritoneal mast cells of Sprague-Dawley rats maintained under pathogen-free conditions. The distribution of IgE content in the mast-cell populations was extremely variable. Up to 30% of the mast cells in individual populations contained little or no IgE, but very few if any of the cells lacked IgE receptors. On average, 60-70% of the receptors available for binding were occupied by IgE in these normal rats.

Influence of prolonged treatment with topical corticosteroid (fluticasone propionate) on early and late phase nasal responses and cellular infiltration in the nasal mucosa after allergen challenge

We have examined the effect of prolonged treatment with topical corticosteroid on allergen-induced early and late nasal responses and the associated inflammatory cell infiltrate in grass pollen sensitive allergic rhinitics. Following a randomized double-blind 6 week treatment period with fluticasone propionate 200 micrograms aqueous nasal spray twice daily or matched placebo spray, nasal provocation was performed using Timothy grass pollen extract. Nasal symptoms were recorded at intervals from 0 to 24 h. Nasal biopsies were performed before treatment and at 24 h after allergen and processed for immunohistology. When corticosteroid-treated patients were compared with the placebo group there was an approximately 50% decrease in the size of the early (0-60 min) response and almost complete inhibition of late (1-24 h) nasal symptoms after allergen challenge. After allergen challenge markedly fewer T lymphocytes and CD25+ (interleukin-2 receptor bearing) cells were observed in both the epithelium and submucosa in fluticasone treated patients compared with the placebo group. Significantly less total and activated eosinophils were observed, particularly within the nasal epithelium. Submucosal mast cell counts were decreased, whereas increased numbers of submucosal neutrophils were observed. These results confirm that topical corticosteroid treatment inhibits allergen-induced early and late nasal responses. This may possibly occur following a decrease in T lymphocytes and/or mast cells and their products and a consequent reduction in tissue eosinophilia.

Metachromatic, IgE-bearing and tryptase-containing cells on the nasal mucosal surface in provoked allergic rhinitis

We studied the relationship between mast cells or basophils and symptoms in provoked allergic rhinitis. Nasal brush and lavage samples were obtained before nasal allergen challenge and every 2 h for 12 h after the challenge in 10 allergics and 3 controls. The cells were identified by their metachromatic staining properties (brush and lavage samples) or with immunohistochemical methods using specific antibodies to IgE and tryptase, a selective mast-cell marker (brush samples). Histamine was determined in the brush samples using liquid chromatography. After an initial decrease, the numbers of metachromatic, IgE-bearing and tryptase-containing cells, as well as the histamine content of the cells in the brush samples, increased during the subsequent observation hours. The prechallenge cell and histamine values correlated with the symptom score 15 min after the challenge. The prechallenge lavage samples lacked metachromatic cells, but these cells were found in increasing numbers after the provocation. Three of the patients differed from the remaining seven in that their prechallenge brush samples contained many positively stained cells. All patients showed a positive cellular response to the allergen challenge, but these three individuals showed the most vivid response. The morphology of the metachromatic cells in the prechallenge brush samples agreed with that of mast cells, but the morphology of metachromatic cells which outnumbered tryptase-containing cells in samples at 8 to 12 h rather agreed with their being basophils.

Mast cells and mediators in the nasal mucosa after allergen challenge. Effects of four weeks' treatment with topical glucocorticoid

The study focuses on the relationship between the tissue density of mast cells, the tissue histamine levels and the levels of markers of mast cell activation after an allergen challenge of the nasal mucosa of allergic patients. The effect of 4 weeks' treatment with a topical glucocorticoid, fluticasone propionate, was studied in a double-blind, placebo-controlled study of 25 hay fever patients. Nasal biopsies were obtained before and after the treatment period for the evaluation of mast cell density and tissue histamine levels. Nasal challenges were performed at 2-week intervals for 8 weeks using a standardized nasal lavage model. TAME-esterase was analysed in the returned lavage fluid from all the challenges (weeks 0-8), while the levels of histamine and tryptase were analysed in lavage fluids from challenges performed before and after the treatment period (weeks 0 and 4). The symptoms of nasal allergy were assessed after each challenge. Treatment with fluticasone propionate did not influence mast cell density, the tissue histamine concentration, the lavage histamine levels or the TAME-esterase activity, while a reduction in nasal symptoms and tryptase in nasal lavage fluid was revealed. Our present study again emphasizes the fact that the mast cell is an important trigger cell in the immediate nasal allergic response. The study also demonstrates the usefulness of the measurements of tryptase as an indicator of both mast cell activation and the efficacy of topical steroid treatment.

Mast cells and eosinophils in the allergic mucosal response to allergen challenge: changes in distribution and signs of activation in relation to symptoms

An allergen challenge was performed in 10 asymptomatic patients with strictly seasonal allergic rhinitis. For comparison; seven nonallergic subjects were challenged with allergen, and seven allergic patients were challenged with diluent. Cell samples, obtained with use of a brush technique to recover cells from within the epithelium and nasal lavage to collect cells from the epithelial surface, and symptom scores were taken before challenge and at 2-hour intervals during 12 hours. The cell suspensions were cytocentrifuged onto object slides for light microscopy. Histamine was determined in the cell pellets. In brush samples from the allergic patients challenged with allergen, eosinophils, expressed as a percentage of the total granulocytes, increased from 4.3% +/- 2.7% (mean +/- SEM) to 10.3% +/- 3.8% (p < 0.05) 4 hours after challenge. This level was maintained for up to 12 hours. A similar increase was noted in the lavage specimens 2, 6, and 8 hours after the challenge. In the brush samples the proportion of eosinophils containing two or more cytoplasmic vacuoles, taken as a sign of activation, increased from 20% to 72% (p < 0.05) 8 hours after provocation. In brush samples from the allergic patients challenged with allergen, the numbers of metachromatic cells increased to a maximum of eightfold at 10 hours. In the lavage specimens, no metachromatic cells were observed before provocation, but they progressively increased in number 2 to 12 hours after provocation. Cell pellet histamine content decreased temporarily 2 to 4 hours after challenge (p < 0.05) in brush samples from allergen-challenged allergic patients. The local metachromatic cell density before challenge, as reflected in the brush specimens, correlated with nasal congestion, sneezing, and the degree of eosinophilia.

Tryptase in nasal lavage fluid after local allergen challenge. Relationship to histamine levels and TAME-esterase activity

The activation of mast cells is generally considered to be an important trigger mechanism in the immediate allergic response. This study focused on the determination of three markers of mast cell activation after an allergen challenge. Nasal allergen challenges were performed in 25 subjects with seasonal allergic rhinitis using three allergen doses increasing in 10-fold steps in a standardised nasal lavage model for the subsequent recovery of the markers of mast cell activation. The levels of histamine and tryptase in the nasal lavage fluid were determined using radioimmunoassays, while the TAME-esterase activity was determined using a radiochemical technique. The nasal symptoms obtained on challenge were assessed using a scoring technique. The allergen challenge resulted in significant increases in the levels of all three markers, tryptase, histamine and TAME-esterase. In the individual measurements after the challenges there was a highly significant correlation between the TAME-esterase levels and the tryptase levels (r = 0.71; P less than 0.001), while the generation of histamine and tryptase was not significantly correlated. When comparing the cumulative generation of the three markers, significant correlations were found between all three. Allergen challenges in six non-allergic controls using the same technique did not result in any increase in tryptase levels. The findings suggest that the determination of tryptase in nasal lavage fluid may be a valuable indicator of mast cell activation in the upper airways.

Macrophages on the nasal mucosal surface in provoked and naturally occurring allergic rhinitis

Macrophages are the most common cell type residing in the lumen of the lower airways. However, very little is known about the presence and putative pathogenic implications of macrophages in the upper airways. Using specific immunohistochemical techniques, the presence of and changes in macrophage density were studied before and after allergen exposure in the laboratory and during natural allergen exposure of subjects with seasonal allergic rhinitis. The monoclonal antibody EBM 11 combined with the alkaline phosphatase-anti-alkaline phosphatase-technique was applied on cytospin-prepared slides. In the challenge experiment, 0.5 +/- 0.2% (mean +/- SEM; n = 10) of the total cell number were positive for the EBM 11 marker before challenge, thereby not differing from the controls (0.2 +/- 0.2%; mean +/- SEM; n = 3). Local allergen challenge induced an increase of these cells to a peak of 1.3 +/- 0.4% after 4 h (p less than 0.05). During seasonal exposure there was also a similar increase, from 0.7 +/- 0.2 to 1.3 +/- 0.3% (p less than 0.05; n = 11) in placebo-treated patients and from 0.7 +/- 0.2 to 1.6 +/- 0.4% (p less than 0.05; n = 11) in patients treated with topical glucocorticoids. There was, however, no direct relationship between nasal symptoms and number of macrophages present on the mucosal surface. The study indicates that macrophages are involved in the inflammatory processes of allergic rhinitis.

Priming effect of a birch pollen season studied with laser Doppler flowmetry in patients with allergic rhinitis

Nasal mucosal provocation tests were done on eight patients with seasonal allergic rhinitis before and after a birch pollen season. The effects on nasal microvascular blood flow were detected by means of laser Doppler flowmetry. The patients reacted to the birch pollen provocation with an increase in blood flow. This increase was greater after the pollen season than before, when the same pollen doses were used, indicating a priming phenomenon of the resistance vessels.

Allergic reaction of the human nasal mucosa studied with laser Doppler flowmetry

The laser Doppler flowmeter is a new instrument that reflects a different physiological parameter other than rhinomanometry for examining the vascular bed of the nasal mucosa. Mucosal blood flow in allergic rhinitis may be an important, but so far little studied, factor. Laser Doppler flowmetry was used to study nasal mucosal microcirculation in seven asymptomatic patients with allergic rhinitis. Topical provocation with birch pollen extract showed a statistically significant dose-dependent increase in blood flow. The method seems useful as an in-vivo model for studying allergic rhinitis.

Rhinomanometry at selection for adenoidectomy

The effect of adenoidectomy in 90 consecutive children was related to nasal obstruction preoperatively in order to improve selection for the operation. Nasal airway resistance was evaluated by anterior rhinomanometry. The adenoidectomy had the best effect on the children with highest nasal airway resistance, after nasal decongestants. Rhinomanometry was found to be a useful method for the selection of children for adenoidectomy.