11

Sensitization to aeroallergens , animal Sensitization to aeroallergens , animal dander , house dust mites and dander , house dust mites and

moulds among patients with moulds among patients with allergic allergic rhinitisrhinitis in warm dry climates in warm dry climates

Abbas H. AlsaeedAbbas H. Alsaeed Assistant Professor and Consultant HematologistAssistant Professor and Consultant Hematologist

King Saud University, College of Medical Sciences King Saud University, College of Medical Sciences Dept. Of Clinical Laboratory Sciences Dept. Of Clinical Laboratory Sciences

22

Variations in Defining Allergic RhinitisVariations in Defining Allergic Rhinitis

Allergic rhinitis was defined as the self-reported Allergic rhinitis was defined as the self-reported presence, in the previous year, of usual nasal presence, in the previous year, of usual nasal blockage and discharge apart from colds or the blockage and discharge apart from colds or the flu, provoked by allergens, with or without flu, provoked by allergens, with or without conjunctivitis (Ng & Tan, 1994) conjunctivitis (Ng & Tan, 1994)

Rhinitis was defined as sneezing or a runny or Rhinitis was defined as sneezing or a runny or blocked nose not due to a cold or the flu (Sly, blocked nose not due to a cold or the flu (Sly, 1999)1999)

Individuals with rhinitis were defined as those Individuals with rhinitis were defined as those suffering with three or more symptoms of suffering with three or more symptoms of rhinitis either throughout the year (perennial) or rhinitis either throughout the year (perennial) or for part of the year (seasonal) (Frosh et al 1999)for part of the year (seasonal) (Frosh et al 1999)

33

BackgroundBackground

PollutantsPollutants have a direct effect on the nose by have a direct effect on the nose by causing cellular damage and stimulating the causing cellular damage and stimulating the release of inflammatory mediators (Bascom, release of inflammatory mediators (Bascom, 1991).1991).

Prevalence rates of rhinitis symptoms among Prevalence rates of rhinitis symptoms among office workers reported in the western office workers reported in the western countries were around 30%, but could be as countries were around 30%, but could be as high as 60% in some offices (Finnegan 1984; high as 60% in some offices (Finnegan 1984; Viegi et al 1991)Viegi et al 1991)

44

Symptoms of Allergic RhinitisSymptoms of Allergic Rhinitis

* Sensitive to specific allergens, e.g. dust* Sensitive to specific allergens, e.g. dust * Pruritus of the nose, eyes palate, ears* Pruritus of the nose, eyes palate, ears * Sneezing more than two at a time* Sneezing more than two at a time * Watery rhinorrhoea* Watery rhinorrhoea * Coexistant asthma or eczema* Coexistant asthma or eczema * Seasonal symptomas* Seasonal symptomas * Family history of allergies.* Family history of allergies.

55

Classification Allergic RhinitisClassification Allergic Rhinitis Seasonal Allergic Seasonal Allergic

Rhinitis (Hayfever) Rhinitis (Hayfever) (SAR(SAR))

Perennial Allergic Perennial Allergic Rhinitis (PARRhinitis (PAR))

Occupational Occupational AllergensAllergens

Pollen from a variety of Pollen from a variety of trees, grasses, and trees, grasses, and weeds.weeds.

HDM, Mold, Animal HDM, Mold, Animal epithelial dander, Food epithelial dander, Food (rare)(rare)

ChemicalsChemicals

66

Perennial Allergic Rhinitis (PAR)Perennial Allergic Rhinitis (PAR)

Patients with PAR are more likely than those Patients with PAR are more likely than those with SAR to have asthma (Kubetin 2001).with SAR to have asthma (Kubetin 2001).

Positive family history of allergic rhinitis.Positive family history of allergic rhinitis.

Personal history of collateral allergy such as Personal history of collateral allergy such as eczematous dermatitis, urticaria, and/or eczematous dermatitis, urticaria, and/or asthma.asthma.

77

Non-allergic TriggersNon-allergic Triggers

* Cold air* Cold air * Smoke and perfumes* Smoke and perfumes * Strong odors* Strong odors * Spicy/hot food* Spicy/hot food * Alcohol* Alcohol * Pregnancy / hormones* Pregnancy / hormones * Decongestant nasal sprays* Decongestant nasal sprays• * Medications, e.g. antihypertensive agents* Medications, e.g. antihypertensive agents• (Druce 1998).(Druce 1998).

88

Symptoms of non-allergic rhinitisSymptoms of non-allergic rhinitis

* History of negative allergen specific IgE * History of negative allergen specific IgE test test

* Sensitive to temperature changes, smoke, * Sensitive to temperature changes, smoke, perfume or environmental irritants perfume or environmental irritants

* Adult onset of symptoms* Adult onset of symptoms * Nasal crusting or drying.* Nasal crusting or drying.

99

Common ComorbidityCommon Comorbidity

20-15% of allergic rhinitis patients had asthma20-15% of allergic rhinitis patients had asthma 75-80% of asthma patients had allergic rhinitis75-80% of asthma patients had allergic rhinitis (Kirn 2001).(Kirn 2001).

PARPARSARSAR

SinusitisSinusitis50%50%23%23%

AsthmaAsthma22%22%16%16%

Otitis MediaOtitis Media14%14%14%14%

1010

ObjectiveObjective

1- To investigate sensitization to 1- To investigate sensitization to aeroallergens, animal dander, HDM and aeroallergens, animal dander, HDM and mould in adult patients with allergic rhinitis in mould in adult patients with allergic rhinitis in warm dry climates using an immunoblot warm dry climates using an immunoblot assay. assay.

2- To estimate the prevalence of rhinitis 2- To estimate the prevalence of rhinitis symptoms in warm climate.symptoms in warm climate.

3- To study the relationship between rhinitis 3- To study the relationship between rhinitis symptoms and allergens.symptoms and allergens.

1111

SubjectsSubjects

Thirty–eight adult patients (25 males and Thirty–eight adult patients (25 males and 13 females) with diagnosed allergic rhinitis13 females) with diagnosed allergic rhinitis

without a previous history of treatment without a previous history of treatment attending the outpatient ENT clinic, from attending the outpatient ENT clinic, from April 2002 to March 2005April 2002 to March 2005 on Alflah on Alflah International Hospital, Saudi Arabia.International Hospital, Saudi Arabia.

1212

InvestigationsInvestigations * History: present illness, past medical history, * History: present illness, past medical history,

family history, environmental family history, environmental history, and impact on quality of life.history, and impact on quality of life.

* * Physical exam: nose, eyes, ears, lung, skin.Physical exam: nose, eyes, ears, lung, skin. * Nasal exam with rhinoscope / flexible * Nasal exam with rhinoscope / flexible

nasendoscope. nasendoscope. * Nasal smear for eosinophils.* Nasal smear for eosinophils. * Nasal mucociliary clearance assessment: * Nasal mucociliary clearance assessment:

saccharin test, and ciliary best frequency saccharin test, and ciliary best frequency measurement. measurement.

* Nasal airway assessment.* Nasal airway assessment. * Allergy tests: Allergen specific IgE* Allergy tests: Allergen specific IgE

1313

Allergy Test (Method)Allergy Test (Method)

TESTTESTMETHODMETHOD

Blood Blood TestTest

allergen immunoblot assayallergen immunoblot assay

((RIDA allergen screenRIDA allergen screen)) Blood serum is Blood serum is combined with allergen combined with allergen

in in troughtrough Radio-allergosorbent allergy Radio-allergosorbent allergy testing (RAST)testing (RAST)

Blood serum is Blood serum is combined with allergen combined with allergen in test tubein test tube..

Provocation testingProvocation testingDirect exposure (e.g. Direct exposure (e.g. via inhalation or via inhalation or ingestion to a likely ingestion to a likely allergenallergen

Skin TestSkin TestPrick testingPrick testingPercutaneousPercutaneous

Scratch testingScratch testingPercutaneousPercutaneous

Intradermal testingIntradermal testingIntradermal injectionIntradermal injection

1414

METHODMETHOD Allergens are coatedAllergens are coated to the surface of to the surface of

nitrocellulose membranes lying in a nitrocellulose membranes lying in a reaction trough. reaction trough.

Patient serum pipettedPatient serum pipetted into the reaction into the reaction trough and incubated at RM, washing.trough and incubated at RM, washing.

Allergy screen detection antibodyAllergy screen detection antibody were were added and incubated again at RM, added and incubated again at RM, washing. washing.

Streptavidin conjugate with alkaline Streptavidin conjugate with alkaline phosphatase that binds to biotinphosphatase that binds to biotin in the in the test fields, and incubated at RM, test fields, and incubated at RM, washing. washing.

1515

ContinueContinue Substrate a specific enzyme color reaction of Substrate a specific enzyme color reaction of

alkaline phosphatasealkaline phosphatase, and incubated at RM., and incubated at RM. The reaction stopped by The reaction stopped by rinsing with waterrinsing with water

and analysis the results on the test strips and analysis the results on the test strips ((RIDA allergy screen 2002RIDA allergy screen 2002).).

Negative control had not been coated with Negative control had not been coated with allergen, biotin-labelled bovine serum albumin allergen, biotin-labelled bovine serum albumin had been applied as had been applied as positive control.positive control.

The color intensity on the test fields is directly The color intensity on the test fields is directly reflect to specific IgE antibody in the serum of reflect to specific IgE antibody in the serum of the patients.the patients.

1616

Figure ( ) Illustrates the results appearance on Figure ( ) Illustrates the results appearance on

the surface of nitrocellulose membranethe surface of nitrocellulose membrane

1717

ResultsResults Specific IgE antibodies were detected in 65.8% Specific IgE antibodies were detected in 65.8%

of all the subjects . of all the subjects . Males demonstrated a higher rate than females Males demonstrated a higher rate than females

(76% vs. 46.2%) or a M/F ratio of ~ 2:1.(76% vs. 46.2%) or a M/F ratio of ~ 2:1. The sensitization rate was highest for pollen The sensitization rate was highest for pollen

while results for the other allergen groups are while results for the other allergen groups are as follows : as follows :

pollen ( 68.3%), animal dander (23.9%) ,HDM pollen ( 68.3%), animal dander (23.9%) ,HDM (6.0%) and moulds (1.8%). (6.0%) and moulds (1.8%).

Among allergenic pollen mixed grasses were Among allergenic pollen mixed grasses were the most common cause of sensitization (11.1%) the most common cause of sensitization (11.1%) while alder, birch, rye and oak have the same, while alder, birch, rye and oak have the same, albeit lower sensitization rates ( 9.4%). albeit lower sensitization rates ( 9.4%).

These plants are commonly cultivated for These plants are commonly cultivated for greening purposes in urban areas .greening purposes in urban areas .

1818

Continue resultsContinue results

Sensitization rate to cat and dog dander are Sensitization rate to cat and dog dander are (9.4% and 8.5% respectively), while dander (9.4% and 8.5% respectively), while dander from horse, guinea pig and golden hamster from horse, guinea pig and golden hamster caused lower rates of sensitization (3.4% - caused lower rates of sensitization (3.4% - 1.7%). 1.7%).

Dermatophagoides pteronyssinusDermatophagoides pteronyssinus and and Dermatophagoides farinaeDermatophagoides farinae are the most are the most prevalent indoor sensitizers (4.3% and prevalent indoor sensitizers (4.3% and 1.7%, respectively). 1.7%, respectively).

Sensitization to mould is relatively rare Sensitization to mould is relatively rare ( 1.8%).( 1.8%).

1919

Table ( ) The relationship between Table ( ) The relationship between absent and present of allergen specific absent and present of allergen specific

IgE in rhinitis patientsIgE in rhinitis patients

ParametersParametersNoNo..AllergenAllergen

absentabsent

AllergenAllergen

presentpresent

P valueP value

PatientsPatients 38381313 ))34.2%34.2% ( (

2525 ))65.8%65.8%((

< <0.050.05

MaleMale 25250606 ))24.0%24.0%

1919 ))76.0%76.0%((

< <0.050.05

FemaleFemale 13130707 ))53.8%53.8%((

0606 ))46.2%46.2%((

0.50.5

2020

Table ( ) Distribution of allergen antibodies in Table ( ) Distribution of allergen antibodies in rhinitis patientsrhinitis patients

AllergenAllergen

SystemSystem

AllergenAllergen

Ab. No.Ab. No.

AllergenAllergen

Ab. %Ab. %

AntibodiesAntibodies

System %System %

PollensPollens

AlderAlder

BirchBirch

HazelHazel

Mixed Gra.Mixed Gra.

RyeRye

MugwortMugwort

PlantainPlantain

OakOak

1111

1111

1010

1313

1111

88

55

1111

9.49.4

9.49.4

8.58.5

11.111.1

9.49.4

6.86.8

4.34.3

9.49.4

68.368.3

2121

ContinueContinue AllergenAllergen

SystemSystem

AllergenAllergen

Ab. No.Ab. No.

AllergenAllergen

Ab. %Ab. %

AntibodiesAntibodies

System %System %

DanderDander

catcat

HorseHorse

DogDog

Guinea pigGuinea pig

Golden Ha.Golden Ha.

RabbitRabbit

1111

44

1010

11

22

--

9.49.4

3.43.4

8.58.5

0.90.9

1.71.7

--

23.923.9

2222

ContinueContinue

HDMHDM

D. pterony.D. pterony.

D. FarinaeD. Farinae

22

55

1.71.7

4.34.3

6.06.0

MouldMould

A. AlternataeA. Alternatae

Pen. NotatumPen. Notatum

Cldsp. Hebar.Cldsp. Hebar.

Asp. Fumiga.Asp. Fumiga.

--

--

11

11

--

--

0.90.9

0.90.9

1.81.8

TotalTotal117117100100100100

2323

Table ( ) Patients with one or multiple allergen Table ( ) Patients with one or multiple allergen antibodies developedantibodies developed..

No. of AllergenNo. of Allergen

Ab. developedAb. developed

No. of PatientsNo. of Patients

(%)(%)

Sensitized Pt.Sensitized Pt.

(%)(%)

11

22

33

44

55

66

77

88

99

1111

06 (15.8%)06 (15.8%)

01 (2.6%)01 (2.6%)

03 (7.9%)03 (7.9%)

02 (5.3%)02 (5.3%)

03 (7.9%)03 (7.9%)

03 (7.9%)03 (7.9%)

01 (2.6%)01 (2.6%)

04 (10.5%)04 (10.5%)

01 (2.6%)01 (2.6%)

01 (2.6%)01 (2.6%)

24 %24 %

04 %04 %

12 %12 %

08 %08 %

12 %12 %

12 %12 %

04 %04 %

16 %16 %

04 % 04 %

04 %04 %

Total Total 65.165.1100100

2424

0

2

4

6

8

10

12%

Cas

es N

o.

Winter Spring Summer Autumn

Figure (2) Relative prevalence of allergens & seasons: the allergen clender

Pollens Dander HDM Moulds

2525

Report of Prevalence Rates in Allergic RhinitisReport of Prevalence Rates in Allergic Rhinitis(variation in methodology)(variation in methodology)

PrevalencePrevalenceAgeAgeCountryCountryYearYear

24.0%24.0%16-6516-65UKUK19911991

62.5%62.5%High schoolHigh schoolTurkeyTurkey19941994

51.0%51.0%High schoolHigh schoolTurkeyTurkey19961996

27.6%27.6%6-76-7SingaporeSingapore19941994

41.5%41.5%12-1512-15SingaporeSingapore19941994

22.0%22.0%7-177-17DenmarkDenmark20002000

15.9%15.9%20-4420-44ItalyItaly20022002

26.3%26.3%U studentU studentBangkokBangkok20022002

2626

Prevalence of Rhinitis in UKPrevalence of Rhinitis in UK

PrevalencePrevalenceAgeAgeAuthorAuthorYearYear

35.1%35.1%6-76-7Lau et alLau et al..19981998

44.0%44.0%13-1413-14Leung et alLeung et al..19971997

29.8%29.8%12-1812-18Leung et alLeung et al..19971997

49.5%49.5%WorkersWorkersTong et alTong et al..20012001

2727

DiscussionDiscussion

2828

2929

ConclusionsConclusions

The results of this study show that even in warm The results of this study show that even in warm climates pollen , animal dander and HDM climates pollen , animal dander and HDM allergens may be important sensitizing allergens . allergens may be important sensitizing allergens . Pollens of local horticultural plants are the main Pollens of local horticultural plants are the main sensitizing allergens among patients with allergic sensitizing allergens among patients with allergic

rhinitis in the locality studiedrhinitis in the locality studied. .

The practice of greening the country seems to The practice of greening the country seems to contribute to increased rates of allergic contribute to increased rates of allergic sensitization of persons prone to allergic rhinitis . sensitization of persons prone to allergic rhinitis . Local environmental and genetic factors are Local environmental and genetic factors are probably involved in the pathogenesis of the probably involved in the pathogenesis of the

diseasedisease . .

3030

TreatmentTreatment

Allergen Allergen avoidanceavoidance

* *Identification of the Identification of the responsible allergensresponsible allergens

* *Health education on allergen Health education on allergen avoidanceavoidance

Medical treatmentMedical treatment * *AntihistaminesAntihistamines..

* *Topical corticosteroidsTopical corticosteroids..

* *AnticholinergicsAnticholinergics..

* *DecongestantsDecongestants

Immunotherapy-injectionImmunotherapy-injection

SublingualSublingual

3131

TreatmentTreatment

SymptomsSymptomsSymptomatic treatmentsSymptomatic treatments

Nasal obstruction Nasal obstruction due to nonallergic due to nonallergic rhinitisrhinitis

* *Azelastine HCL nasal Azelastine HCL nasal sprayspray

* *Oral decongestantOral decongestant

Non-purulent chronic Non-purulent chronic post nasal drippost nasal drip

* *Increase water intakeIncrease water intake..

* *Nasal saline irrigationNasal saline irrigation..

* *Humidity to bedroomHumidity to bedroom..

Bilateral anterior Bilateral anterior rhinorrhearhinorrhea

* *Intranasal cortisteroidIntranasal cortisteroid..

* *Atrovent sprayAtrovent spray..

* *Nasal salineNasal saline