2014. Allergic Rhinitis: signs and symptoms

9/5/2014 Disclosures  Dr. Brooks  Advisory board, research grant ‐ United Allergy Services  speaker’s bureau ‐ Merck Edward G. Brooks, MD Pediatr...
Author: Gyles Griffith
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9/5/2014

Disclosures  Dr. Brooks  Advisory board, research grant ‐ United Allergy Services  speaker’s bureau ‐ Merck

Edward G. Brooks, MD Pediatrics Grand Rounds Sept 5, 2014

Learning Objectives  Differential diagnosis of hypersensitivity disorders  Management of hypersensitivity

Case #1  5 y/o boy with 3 month history of nasal congestion,

nighttime cough, bad breath, intermittant purulent rhinnorhea alternating with clear rhinnorhea, episodes of sneezing/nasal itching  OTC cold meds haven’t worked  This has been recurrent for the past 2 years  Possible diagnoses?

 Bacterial sinusitis vs Allergic Rhinitis

Allergic Rhinitis: signs and symptoms  Since this is not a board test you get to ask additional

questions:  number and duration of antibiotic courses  last time child was completely clear  allergic triggers  family Hx. sinus/allergic disease  seasonality of symptoms  exposures (siblings, school, allergens, pollutants, etc.)  breathing problems (asthma, CF)  other infections (immunodeficiency)  foul discharge from nare unilaterally (foreign body)

 

Provoked by exposure to environmental allergens Common Symptoms: – Nasal, eye itching – Sneezing, clear rhinorrhea, post nasal drip, watery eyes tearing – Mouth breathing, sleep disturbances - Mucosal edema with nasal congestion / obstruction – “Sinus” headache, ear pressure - ostial & eustachian tube dysfunction – Reduced taste and smell olfactory dysfunction

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Allergic Rhinitis:

Allergic Rhinitis:

signs and symptoms

signs and symptoms

Eyes: – conjunctivitis, Dennie’s lines, allergic “shiners” Nose: – edematous/pale/enlarged nasal turbinates, clear/thin mucoid rhinitis, polyps, transverse nasal crease from “allergic salute” Ears: – otitis media, retracted tympanic membrane from ET dysfunction Throat: – prominent lymphoid patches (cobblestoning) lateral pharyngeal bands



Allergic conjunctivitis







allergic shiners

Eyes: – conjunctivitis, Dennie’s lines, allergic “shiners” Nose: – edematous/pale/enlarged nasal turbinates, clear/thin mucoid rhinitis, polyps, transverse nasal crease from the “allergic salute” Ears: – otitis media, retracted tympanic membrane from ET dysfunction Throat: – prominent lymphoid patches (cobblestoning), lateral pharyngeal bands

Allergic crease

Allergic Rhinitis ‐ triggers

Allergic Rhinitis: signs and symptoms 









Eyes: – conjunctivitis, Dennie’s lines, allergic “shiners” Nose: – edematous/pale/enlarged nasal turbinates, clear/thin mucoid rhinitis, polyps, transverse nasal crease from the “allergic salute” Ears: – otitis media, retracted tympanic membrane from ET dysfunction Throat: – prominent lymphoid patches (cobblestoning), lateral pharyngeal bands





Allergic crease

Allergic salute

Provoked by exposure to environmental allergens Perennial (year round) (mites, molds, pets) Seasonal (intermittent) (pollens)

Allergic salute

Is it allergy or a URI?

Treatment of Allergic Rhinitis

% of Patients with Symptom  Avoidance – allergens and irritants (smoke, chemicals)  Antihistamines - (pruritis, rhinorrhea)  Corticosteroids-topical (all symptoms)  Leukotriene Receptor Antagonists (congestion)  Decongestants-topical or systemic (congestion)

70

Sore Throat

50

Cough

40

Nasal Drainage

 Anticholinergics

30

 Cromolyn (congestion)

20

 Allergen Immunotherapy (desensitization)

Fever

60

10 0

1

2

3

4

5

6

7

8

9

10

11 12 13 14

Day of Illness

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Acute Bacterial Rhinosinusitis

Most Rhinosinusitis Results From a Cycle of Mucosal Inflammation Mucosal Swelling (URI, allergy, environment)

• Most often preceded by a viral URI • A [probable] diagnosis may be made if a viral URI has not improved after 10 days or has worsened after 5 to 7 days or if symptoms are out of proportion to a typical URI • Common bacteria: - Streptococcus pneumoniae -

Hemophilus influenzae

-

Moraxella catarrhalis

-

Staphylococcus aureus, atypical bacteria (M. pneumoniae)

Bacterial Infection

Ostial Obstruction

Mucous Stasis (antihistamines)

Atopic disease Asthma, Allergic Rhinitis, Food allergy, Eczema

The Atopic March In utero  Genetic predisposition  Maternal influence-fetal programming  Environmental factors

Infancy  Eczema  Food Allergy

Toddler  Asthma

School Age  Asthma  Allergic rhinitis

Cells of Allergic Inflammation

Allergic Sensitization

Antigen Presenting Cell B Cell

IL-4 IL-13 IL-3 IL-4 IL-6 IL-9 IL-13

TH2 Cell IL-3 IL-5 GM-CSF Eotaxin TNF- IL-4

IgE Mast Cell

VCAM

ICAM

Vascular Endothelium

Eosinophil Neutrophil

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Case #2

Late Phase Reaction in Nasal Mucosa

18 month male with episode of facial swelling after eating peanut butter.

The late phase of the Type I hypersensitivity

Infiltration of inflammatory cells, especially eosinophils, lymphocytes

At age 3 y/o developed welts after touching peanuts. What’s he allergic to? Do you really need a test to tell you this? What’s the treatment? What do you tell the family?

At 5 y/o he developed acute urticaria over the eye when a classmate threw a peanut butter and jelly sandwich at him. At age 6 y/o, developed throat tightness when he ate a chocolate chip cookie at school. Upon closer inspection of the package, it read… “May contain peanuts and/or tree nuts”

But what if the story was “ He went to a school party, and we have no idea what he ate?” What do you do?

Specific IgE Testing Skin Prick Testing

ImmunoCap

In‐Vitro testing

Positive = 3 mm wheal > negative control Good negative predictive value ~ 50% false positive

Case #3

Major Food Allergens

USA:  Milk  Egg  Peanuts  Tree nuts  Seafood

Israel:  Egg  Milk  Sesame seeds

What’s the diagnosis?

Anaphylaxis Singapore:  Birdsnest  Seafood  Egg  Milk

Treatment?

Rx: epinephrine and anti-histamines Had 2 more episodes after eating chocolate syrup at a restaurant and after exposure to hand sanitizer on the school bus What’s the allergen?

France:  Egg  Peanuts Italy:  Milk  Milk  Mustard  Egg  Seafood Sampson et al.

10 yo girl had 3 episodes of lip and tongue swelling, throat tightness, dyspnea after putting Neosporin on her lips, after eating Raman noodles and after eating chicken nuggets.

Australia:  Milk  Egg  Peanuts  Sesame seeds

Allergy testing for common food, insect and inhalant allergens was negative. Common ingredient: Methylparaben Common preservative used in just about EVERYTHING! Also occurs naturally in fruits (blueberries)

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Anaphylaxis definition(s): 1) the acute onset of a reaction (minutes to hours) with involvement of the skin, mucosal tissue or both and at least one of the following: a) respiratory compromise or b) reduced blood pressure or symptoms of end-organ dysfunction 2) two or more of the following that occur rapidly after exposure to a likely allergen for that patient – involvement of the skin/mucosal tissue, respiratory compromise, reduced blood pressure or associated symptoms and/or persistent gastrointestinal symptoms 3) reduced blood pressure after exposure to a known allergen The diagnosis and management of anaphylaxis practice parameter: 2010 Update. JACI 2010

Urticaria

Angioedema

Angioedema Laryngeal edema

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Case #4 12 yo boy with well-controlled asthma was traveling from Midland to San Antonio. During the trip he developed a slight rash and wheezing not responsive to his rescue inhaler. Family drove straight to the ER.

Insect Stings  Imported fire ants stings are a common

etiology for occult anaphylaxis

Dx: asthma exacerbation Rx: steroids and albuterol

 Anaphylaxis in 1% of children stung

No precipitating factors were identified, no URI sx, no new meds, no toxic exposures. He had various snacks during the trip, but had no h/o food allergy.

 Symptoms usually occur within minutes  Local reactions do not predict a severe

What triggered his asthma?

reaction; large local reactions/systemic are associated with slight increased risk  Immunotherapy very effective

 Cutaneous local reactions very common  Systemic reaction in 5-10%

Food allergy testing was negative Testing to imported fire ants positive

Anaphylaxis testing  Serum tryptase – levels peak 60-90 min.

after onset and persist for 6 hours, special handling  24 hour Urinary methyl-histamine  IgE testing – 6 weeks after event  Challenge testing

Emergency treatment of anaphylaxis  Epinephrine (0.01 cc/kg of 1:1000)  0.3 cc (>30 kg, ~ 9 y/o ), 0.15 cc (15-30 kg)  Anti-histamines – primarily short acting H1 antagonists (diphenhydranmine)  Corticosteroids – beneficial in asthma sx, and to prevent late-phase reactions  Remain recumbent if hypotension present (fluid resuscitation)  Observe for 4-8 hours

Indications for Extended Observation • Severe reaction of slow onset • History of previous biphasic reaction • Marked asthmatic component • Ingested antigen (continuous absorption)

 Discharge

Lieberman et al. The diagnosis and management of anaphylaxis practice parameter: 2010 Update.  J Alllergy Clin Immunol.  2010; 126(3):477.

    

Autoinjectable epinephrine Anti-histamines for 24-48 hours Corticosteroids for 24-48 hours Education: avoidance of suspected causative agents F/U allergy eval.

Case #5

Allergic Food Disorders

8 yo girl evaluated for FTT and multiple food allergies

IgE-Mediated PMHx: began vomiting with breast feeding, placed on elemental formula. Had vomiting, GERD, diarrhea, abdominal pain to multiple other foods. Esophageal bx demonstrated >25 Eos/HPF IgE testing showed multiple reactions (lemon > 50 kU/L,

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