ALLERGIC RHINITISPRESENTED BY:K.RATNA DEEPTHIPHARM.D 5TH YEAR

DEFINATION:Allergic rhinitis is an allergic inflammation of the nasal airways. It occurs when an allergen, such as pollen, dust or animal dander (particles of shed skin and hair) is inhaled by an individual with a sensitized immune system.

ALLERGIC RHINITIS CLASSIFICATIONBased on occurrence:1)Seasonal 2)PerennialBased on severity:1) Mild-Intermittent2) Moderate-Severe intermittent3) Mild-Persistent4) Moderate-Severe Persistent.

SymptomsRhinorrheaCough/sneezingNasal congestionPost nasal dripNasal pruritisWatery eyesGeneral fatigueDiminished quality of life

IgEcoated mast cells recognize allergens in the mucosal lining, and undergo degranulation.Preformed histamine, heparin, tryptase, kininogenase, and chymase cause the initial damage.Newly formed mediators include leukotrienes and prostaglandins Pathophysiology EARLY RESPONSES:

These cause vessels to leak leading to watery rhinorrhea, nasal edema/congestion, and sneezing/pruritis

Pathophysiology

LATE RESPONSE: Mast cells also secrete chemokines that promote VCAM, and E selectin expression on endothelial cells. These allow other leukocytes to attach, and migrate into tissues. IL-5 is a potent chemoattractant of eosinophils, T lymphocytes, and macrophages. Over the course of 4 to 8 hours, These cells release there contents, causing further inflammation.

History of allergy testing1872 pollen was identified as the causative factor for fall hay fever. Blakely performed first skin test with pollen extract. 1912 intra dermal test by Schloss 1920s skin prick testing introduced by Lewis and Grant.

SCREENING TESTS

Rapid, efficient, and cost effective method to assess allergy.Most allergic individuals will react to common antigens via in vivo or in vitro techniques.Antigens should be representative of what the patient may encounter, and should be geographically based.

Skin prick/scratchSuperficial skin reaction, does not penetrate dermis.Highly specific, sensitive, convenient and safe.Requires positive (histamine) and negative (saline) control.Droplet of antigen is introduced about 1 mm deep into the skin.

Disadvantages: Patient discomfort

Inter tester variability

Non-standardized allergen extracts, and different

interpretation scales

Intradermal testingA dilute antigen extract is injected into the dermis, and a superficial wheal forms.Causes relatively minimal patient discomfortDisadvantageshigher risk of anaphylaxisTime intensivePossible false positive

SKIN END-POINT TITRATION TESTAntigen intradermaly introducedWheal size measured after ten minutes.Endpoint 1st dilution that causes positive response (additional growth of wheal > 2mm),followed by confirmatory wheal (growth of at least another 2 mm)

CASE ON ALLERGIC RHINITIS

PATIENT NAME: Mr.RS AGE: 57 yrs SEX: M D.O.A: 8/1/13 DEPARTMENT:PULMONOLOGY

SUBJECTIVE PRESENT HISTORY: patient came to hospital with chief complaints of nasal itching,sneezing,clear rhinorhea,stuffiness.

PAST HISTORY Intermittent allergic rhinitis since childhood. HTN(10 yrs)

PAST MEDICATION:DIPHENHYDRAMINE 50mgPSEUDO EPHEDRINE 60 mg TID

OBJECTIVE PHYSICAL EXAMINATION:BODY WT: 65kgCNS: Normal LUNGS: N,CLEAR CVS: S1 S2 GIT: NPR: 75/min BP: 128/82 mm HgSMOKING : NONO DRUG ALLERGY

LAB INVESTIGATION:

COMPLETE BLOOD PICTURE

COMPLETE URINE EXAMINATION

Skin sensitivity test-confirmed sensitivity to tree pollen.

ASSESSMENT:Patient exhibiting classic symptoms of persistent (perennial) allergic rhinitis with intermittent (seasonal) exacerbation, nasal itching, sneezing, water rhinorrhea, congestion.OTHER TESTS:

His history of positive skin test and symptoms, previously responded to anti-histamine also supports diagnosis.The elevated esinophils are mostly seen in allergic state.DIAGNOSIS: ALLERGIC RHINITIS

PLAN

Hydrochloro thiazide, amlodipine is given for HTN.Loratadine /citrazine are given for nasal itching.For ocular itching pheniramine maleate + naphazoline HCL is given, to be used whenever needed.PATIENT COUNSELLING:Patient has been advised not to over use pheniramine eye drops as it may lead to remission of conjunctivitis.Patient should be expained about the drowsy effect of anti-histamine.Avoid the agent which is causing allergy to the patient (changing the environment).

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