CMS250 - Wk 6, Allergy

Allergy Definitions

• Allergy is the clinical manifestation of an adverse immune response after repeated contact with harmless substances such as pollens, mold spores, animal dander, dust mites, foods, or stinging insects.
• Atopy is the predisposition to an immune response against antigens and allergens, leading to CD4+ Th2 differentiation and overproduction of IgE, a Type 1 hypersensitivity reaction.
• Allergic rhinitis is inflammation of nasal mucous membranes caused by an IgE-mediated response to one or more allergens.
• It is one of the more common manifestations of atopy, along with asthma and eczema.

Allergy Epidemiology

• Historically, allergic rhinitis was considered a disease of the nasal airway alone.
• Allergic rhinitis is classified as a component of a systemic allergic response, potentially linked to underlying systemic pathology like asthma or atopic dermatitis.
• 20-30% of adults and up to 40% of children in the U.S. are affected.
• Approximately 40 million people in the U.S. and over 500 million worldwide are affected.
• Allergic rhinitis is the sixth most prevalent chronic illness.
• Treatment costs are at least $1.8 billion annually, including physician visits and medications.
• In 1995, a prevalence of self-reported nasal allergies of 20.9% was found among adult populations according to the European Community Respiratory Health Survey (ECRHS), ranging from 9.5% to 40.9%.
• Rhinitis prevalence has reportedly increased in recent decades across geographical regions, though literature reviews need to address this topic.
• Allergic rhinitis is also one of the most common chronic pediatric disorders.
• In the International Study for Asthma and Allergies in Childhood(ISAAC) 2004, 14.6% of 13-14 yr olds and 8.5% of 6-7 yr olds displayed symptoms of rhinoconjunctivitis linked to allergic rhinitis in 97 countries.
• Self-reported current nasal symptoms at 31.7%, varying from 11.9% to 80.6%.
• Onset can occur at any age, but is greatest in adolescence, then decreasing with age.
• 80% of people get diagnosed before age 20.
• Peak prevalence occurs during the third and fourth decades of life.
• In a longitudinal study, 54.9% of patients showed symptom improvement with 41.6% symptom-free at a 23-year follow-up visit.
• Patients with symptom onset at a younger age showed greater improvement.

Allergy Risk Factors

• Genetic predisposition is greatly indicated: children have a 30% chance of developing allergic rhinitis if one parent is affected, and a 50% chance for those with both parents affected.
• Severity can vary with location and season.
• Risk factors include family history of atopy, male sex, presence of allergen-specific IgE, serum IgE greater than 100 IU/mL before age 6, and higher socioeconomic status.
• A higher risk of allergic rhinitis occurs with early introduction to foods/formula or heavy exposure to cigarette smoking during the first year of life in children.
• Possibly protective factors include breastfeeding, early pet exposure, and the "farm effect".
• A meta-analysis of 8 studies showed a 40% lower risk in subjects who lived on a farm during their first year of life.

Impact of Allergic Rhinitis

• Allergic rhinitis adversely affects school and work performance through sleep deprivation, fatigue, reduced productivity, and absenteeism.
• Economic costs (direct and indirect) are substantial because of the allergy symptoms, prescription and non-prescription medications, and negative side effects of allergy medication.
• Non-life-threatening, but its symptomatic effects significantly diminish quality of life(social and physical functionality, energy and fatigue levels, mental health, sleep).
• It may contribute to sleep disorders, fatigue, and learning problems.

Allergic Rhinitis Diagnostic Approach

• Patient history
• Symptoms
• Physical examination findings
• Allergy testing

Patient History

• This is essential to evaluate allergic rhinitis, focusing on: symptoms (onset, duration, exposures, magnitude of reaction, patterns, chronicity), exacerbating/alleviating factors, seasonal variation, environmental influences, allergies, medical history, past, and current treatments.
• Knowing patient's age at symptom onset can be helpful.
• Constitutional symptoms (headache, malaise, fatigue) are common.
• A personal history of asthma is worth documenting.
• Persistent symptoms may be due to exposure to an indoor allergen.
• Seasonal symptoms or symptoms reproducible from a triggering factor are likely allergic, like environmental allergen exposure with allergen-specific IgE.
• Acute onset (one week or less) usually suggests a viral etiology, acute exacerbation of allergic rhinitis, or a foreign body. Foreign bodies are most commonly unilateral and in children.
• Chronic symptoms with seasonal variations suggest seasonal allergic rhinitis.
• Chronic acute rhinitis often shows postnasal drip, chronic nasal congestion, and obstruction.
• If antihistamines can be taken or intranasal corticosteroids prescribed to improve the symptoms, allergy is probable
• Intranasal or oral decongestants will affect both allergic and nonallergic symptoms.
• Anaphylactic reaction to a particular food or insect usually indicates an atopic patient.
• Rhinitis can be caused by: beta-blockers, acetylsalicylic acid, NSAIDs, ACE inhibitors, and hormone therapy.
• Evaluate the patient's home and work/school environments to determine potential triggers such as: pollens, furred animals, textile flooring/upholstery, tobacco smoke, or the humidity. Seasonal Allergic Rhinitis
• Most commonly caused by pollens and spores.
• Flowering shrub and tree pollens are likely culprits in Spring; flowering plants and grasses in Summer; and ragweed and molds in the Fall. Perrenial Allergic Rhinitis
• Dust, mites, air pollution, and pet dander may be the cause of year-round “perennial rhinitis".
• Genetics factors are determinants of an inherited liklihood.
• Family history of allergies, eczema, or asthma increases the possibilities. Children with parents who have allergies have a >50% chance of becoming allergic themselves.
• Food Allergens such as milk, eggs, soy, wheat, dust mites and inhalent allergens are the major causes of rhinits and comorbidities of atopic dermatitis, otitis media and asthma.

Physical Examination

• Visualization of patient appearance
• Nose exam
• Ears exam
• Sinuses exam
• Posterior oropharynx exam
• Additional exams: Lymph Nodes, Chest and Skin

Visualization

• Conjunctivitis in the eyes
• "Allergic shiners": blue-grey or purple discolouration under the lower eyelids
• Mouth breathing
• Frequent sniffling and/or throat clearing

Nose Examination

• Assess for a "Nasal salute": this is noticed by a transverse nasal crease due to constant rubbing of the nose in an upwards motion
• Endoscopic nasal exam to assess for abnormalities.
• structural abnormalities,like septal deviation, nasal ulcerations, and nasal polyps
• There may be “Cobblestoning" of nasal mucosa, swelling, and discharge
• Boggy, pale, or “bluish” (violaceous) nasal turbinates due to venous engorgement. Compare observations,
• Consider assessment before and after decongesting with a topical decongestant to check differences.

Nasal Polyposis

• Incidence in population is 4% and is more common in males.
• Nasal Popososis is the product of chronic inflammation of the paranasal sinus mucosa.
• Is usually bilateral.
• Unilateral polyps may show concerns for malignancy .
• Nasal prolypsosis is typically benign.

Ears, Sinus and Oropharynx Examination

• Ears typically appear normal, although a pneumatic otoscope should be considered
• Palpate sinuses: May indicate some tenderness if chronic. Teeth sensitivity can be checked.
• Postnasal drip: mucous back of the nose and throat. Enlarged tonsils can indicate allergic rhinitis

Addition Physical exams

• Check Lymphadenopathy, chest, skin as secondary exams

Testing for children

• "allergic shiners", facial grimacing, mouth breathing, and nasal salute are all common indicators
• Check for constant otitis media

Diagnostic Testing

• Allergy Testing has varied recommendations.
• Allergy testing has no recommendations.

Systemic Review

• Tests to treat testing should change the outcomes
• Some testing is specific for classic symptoms
• Testing may be different if there are servere diagnoses.

Skin Allergy Test

• These should be appropriate for certain treatments, and are important when observation is required is symptoms arise.
• There are both test: Skin Prick, Intradermal, and, Serum Testing

Skin Allergy Test

• This is primary method used to identify specific trigers of rhinitis
• This is easily performed in office for immediacy of information.
• it is also specfic and has higher sensitivity, whilst more cost effective
• They are also safe, and requires a trained technician.
• H2-receptor antagonists, tricyclic antidepressants, and anti-IgE monoclonal antibody can all influence the test.
• Skin testing should stop medication before testing. Patients with bad asthma, cardiovascular disease of beta-blocker therapy have a contraindication to this practice

Skin Prick Testing

• This process means: allergen is placed on skin of forearms.
• prick the skin to introduce into the epidermis.
• within 15-20 mins there are positive results.

Intradermal Testing

• This method is more reliable then skick prick and is more consistent
• 0.05 ML Allergen injections underneith the surface of the skin must have a diameter of 4-6 mm.
• Look for results after
• 15-20 minutes, small hive with swell and redness indicate results. For positibe results, there should be a wheal size of 3 millimetres beyond that initial

Serum Test

• These easy atopic tests measures IgE levels against allergens, is cost and time effective.
• RAST name means IgE test but original bloodwork osno longer performed

Allergic Test in Children

• Perform tests, when, if it means a change in therapy

Nasal Cytology

• Only used if there are uncelar diagnoses.
• Middle of inferior turbinate must be swapped immediatey and put on a glass slide
• Air dry then use view under microscrope for an analysis. the inflammation or chemical mediators are responsible for nasal congestion, sneezing, itching, and runny nose.

List of Differentials for Allergies

• Common cold
• Sinutis
• Viral
• Allergic
• Bacteria / Fungal
• seasonal allergic rhinitis
• vasomotor rhinitis
• drug-induced rhinitis
• nasal foreign body

Other Rhinitis Types

• Seasonal / Viral
• Eosinophilic syndromes, NARES / Nasal Polyposis
• Granulomatous rhinitis
• Bacterial Rhinosinusitis
• Vasomotor Rhinitis
• Medication
• Rhinitis of pregnancy
• Hypothyrois
• Medication ie birth control
• Noneosinophilich Syndromes
• Gustatory Rhinitis
• Atrophic Rhinitis

Other Types

• Non allergic, viral infections
• Vasomotor rhinitis
• Rhinitis medicamentosa
• Hormonal and drug-induced rhinitis
• Nonallergic rhinitis with eosinophilia syndrome

Types of Non Allergic Rhinitis

• Elimination of IgE is neccessary
• viral or infection of subtype less common
• Hormonal, and can be known as non allergenic

Viral Rhinitis

• Causs are rhinoviruses, syncatial viruses. bodyaches/ cough
• Is typically only symptomatic care
• S Aureus can occur.

Vasomotor Rhinitis

• Blood to nasal mucosa is caused, with an abnormal autonomic control.
• GERD
• Clear drainage, congestion, pruites can be the effects.
• Temp, houmidity, eating will all cause this, normal seurm IgR is normal here. so there osinflamation.

Drugged Rhinitis

• Medications such as cocaine can cuase drugs
• RHINITIS medicamentosa can cause that

RHinitis Medicamentosa

• Long term over counter usage of tachyphylaxsis results in rebound and obstructioj.

Hormonal Rhinitis

• Pregnancy can cause this because of extra mucus ad hyalournic acid
• 2+ Trimesters.

Allergies

• NARES non allergic with ESNOPHILIA
• Inflamttory with increased mast etc nasal biopsey. They will indicate serveity but will be inhales by inhalation
• 25 is what display marker

Non Allegenic Consideration

• Allegenicity ccan be confusing and diagnositc creitera is confusing
• Pure non allegernic is 23%
• 34% is combiantion of each
• screen and identify combination of rhinotous

Classification of Allergies

• seasonal is caused by pollens, which can be pediatric in children.

Symptoms of Seasonal

• Snezing and watering is typical, worse during morning with aggrevation
• Perrenial is 40percent more common in adults. symtpoms with seacsonal varations but less in intensity
• congention and postnasal drip us typical there less common effects and there irritation with certain allergies and poillrn

Common allergens

• Dust and mold typically
• Infections can influence perennial.

Occupational rhinitis

• From irriants can be caused and worsen throu work
• Symptoms include sneezing congestions of the nose
• Remove of agent, by avoiding particilatr matter

Systems

• May fit seaonal and perennial, sevreity duration.
• MILD has no disturbaces in school, where sevre has distrubance with sleep.

Climarte Effects

• ragweek longer pollations and allergens

Classification

• Duration
• sevreity of week of duration

Associated Asthma and Atopy

• Genetic predisposition
• Presence of allergens
• Key effects in rhinitis
• Hipersnity

Atropic Triad

• astma allerrgitic is all included
• Atropic March- skin 1 year, food allergies, allergry/ seasonal, and than asthma occurs.

Astma

• Allergic rhino can be more sevre
• triggers asthma.

Primary Management and Other Types.

• Phyisican
• Refeer to expert.
• polyps will increase
• fluid and exam should prompt it