11

Sensitization to pollen , animal dander , Sensitization to pollen , animal dander , house dust mites and moulds among house dust mites and moulds among patients with patients with allergic rhinitisallergic rhinitis in warm in warm

dry climatesdry climates

Abbas H. Alsaeed Abbas H. Alsaeed M Med Sci, PhD, CLC, MRCpathM Med Sci, PhD, CLC, MRCpath

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

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

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

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

ANIMAL EPITHELIA DANDERSANIMAL EPITHELIA DANDERS

1-1-CatsCats are considered to be the most highly are considered to be the most highly allergenic animal species for most people. allergenic animal species for most people.

2-2-DogDog, responsible for allergens, usually , responsible for allergens, usually specific to epithelial proteins. specific to epithelial proteins.

3-3-HorseHorse is reported as a source of a very is reported as a source of a very potent allergen. potent allergen. Many patients develop Many patients develop severe allergy, even an indirect contact to severe allergy, even an indirect contact to horse is enough to release symptoms. horse is enough to release symptoms.

55

HOUSE DUST MITES (HDM)HOUSE DUST MITES (HDM)

Dust mites are microscopic organisms, Dust mites are microscopic organisms, belong to the kingdom animalia, belong to the kingdom animalia, phylum phylum arthropodaarthropoda and class and class arachniaarachnia. .

The organism’s genus and species name The organism’s genus and species name are are Dermatophagoides pteronyssinusDermatophagoides pteronyssinus and and Derm. Derm. farinaefarinae. .

HDM is widely suspected to be an important HDM is widely suspected to be an important factor in the pathogenesis of allergic factor in the pathogenesis of allergic disease . disease .

66

MOULDMOULD

Mould, e.g. Mould, e.g. alternaria alternataalternaria alternata is a common is a common and cosmopolitan species occurring on and cosmopolitan species occurring on many plants and other substrates including many plants and other substrates including soils, food and textiles. soils, food and textiles.

It is frequently found on condensed window It is frequently found on condensed window frames and it considered an outdoor mould frames and it considered an outdoor mould and appears when weather is warm. and appears when weather is warm.

AA. . alternataalternata is considered one of the most is considered one of the most allergenic mould in the world (Agarwal et al allergenic mould in the world (Agarwal et al 1982).1982).

77

Symptoms of Allergic RhinitisSymptoms of Allergic Rhinitis

1- Sensitive to specific allergens, e.g. dust1- Sensitive to specific allergens, e.g. dust

2- Pruritus of the nose, eyes palate, ears2- Pruritus of the nose, eyes palate, ears

3- Sneezing more than two at a time3- Sneezing more than two at a time

4- Watery rhinorrhoea4- Watery rhinorrhoea

5- Coexistant asthma or eczema5- Coexistant asthma or eczema

6- Seasonal symptomas6- Seasonal symptomas

7- Family history of allergies.7- Family history of allergies.

88

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

99

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.

1010

Non-allergic TriggersNon-allergic Triggers

1.1. Cold airCold air

2.2. Smoke and perfumesSmoke and perfumes

3.3. Strong odorsStrong odors

4.4. Spicy/hot foodSpicy/hot food

5.5. AlcoholAlcohol

6.6. Pregnancy / hormonesPregnancy / hormones

7.7. Decongestant nasal spraysDecongestant nasal sprays

8.8. Medications, e.g. antihypertensive agentsMedications, e.g. antihypertensive agents

(Druce 1998).(Druce 1998).

1111

Symptoms of non-allergic rhinitisSymptoms of non-allergic rhinitis

1.1. History of negative allergen specific IgE History of negative allergen specific IgE test test

2.2. Sensitive to temperature changes, smoke, Sensitive to temperature changes, smoke, perfume or environmental irritants perfume or environmental irritants

3.3. Adult onset of symptomsAdult onset of symptoms

4.4. Nasal crusting or drying.Nasal crusting or drying.

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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).

PerennialPerennial SeasonalSeasonal

SinusitisSinusitis 50%50% 23%23%

AsthmaAsthma 22%22% 16%16%

Otitis MediaOtitis Media 14%14% 14%14%

1313

AIMSAIMS

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

2- 2- To estimate the prevalence of rhinitis 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.

1414

SubjectsSubjects

Thirty–eight adult patients (25 males and 13 Thirty–eight adult patients (25 males and 13 females) with diagnosed allergic rhinitisfemales) 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 General on General Hospital, Saudi Arabia.Hospital, Saudi Arabia.

1515

InvestigationsInvestigations1.1. 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.

2.2. Physical exam: nose, eyes, ears, lung, skin.Physical exam: nose, eyes, ears, lung, skin.3.3. Nasal exam with rhinoscope / flexible Nasal exam with rhinoscope / flexible

nasendoscope. nasendoscope.4.4. Nasal smear for eosinophils.Nasal smear for eosinophils.5.5. Nasal mucociliary clearance assessment: Nasal mucociliary clearance assessment:

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

6.6. Nasal airway assessment.Nasal airway assessment.7.7. Allergy tests: Allergen specific IgEAllergy tests: Allergen specific IgE

1616

Allergy Test (Methods)Allergy Test (Methods)TESTTEST METHODMETHOD

Blood TestBlood Test allergen immunoblot assayallergen immunoblot assay

(RIDA allergen screen)(RIDA 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 tube.in test tube.

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

Skin TestSkin Test Prick testingPrick testing PercutaneousPercutaneous

Scratch testingScratch testing PercutaneousPercutaneous

Intradermal testingIntradermal testing Intradermal injectionIntradermal injection

1717

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

nitrocellulose membranes lying in trough.nitrocellulose membranes lying in trough.

Patient serum pipettePatient serum pipette into the reaction into the reaction trough.trough.

Allergy screen detection antibodyAllergy screen detection antibody were were added.added.

Streptavidin conjugate with alkaline Streptavidin conjugate with alkaline

phosphatase that binds to biotinphosphatase that binds to biotin in the in the test fields were added. test fields were added.

1818

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

of alkaline phosphatase were addedof alkaline phosphatase were added.. 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-labeled bovine serum allergen, biotin-labeled bovine serum albumin had been applied as albumin had been applied as positive positive control.control.

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

1919

Figure (1) Illustrates the results appearance on Figure (1) Illustrates the results appearance on

the surface of nitrocellulose membranethe surface of nitrocellulose membrane

2020

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.

Parameters Number AllergenAbsent (%)

AllergenPresent (%)

P value

Patients 38 13 (34.2%) 25 (65.8%) < 0.005

Male 25 06 (24.0%) 19 (76.0%) < 0.005

Female 13 07 (53.8%) 06 (46.2% 0. 5

2121

Continue ResultsContinue Results

The sensitization rate was highest for The sensitization rate was highest for pollen while results for the other pollen while results for the other allergen groups are as followsallergen groups are as follows : :

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

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

2222

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), (9.4% and 8.5% respectively),

while dander from horse, guinea pig and while dander from horse, guinea pig and golden hamster caused lower rates of golden hamster caused lower rates of sensitization (3.4% - 1.7%). sensitization (3.4% - 1.7%).

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

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

2323

Animal dander (23.9%) and HDM (6.0%) Animal dander (23.9%) and HDM (6.0%) altogether pose a significant although less altogether pose a significant although less important source of exposure, important source of exposure,

with only rare cases involving mould with only rare cases involving mould (1.72%),(1.72%), leaving pollen as the leading leaving pollen as the leading cause of sensitization, cause of sensitization,

attributable in part to the all too common attributable in part to the all too common utilization of plants in urban areas (like utilization of plants in urban areas (like Riyadh) which are purposely cultivated for Riyadh) which are purposely cultivated for greening purposes and in part to existing greening purposes and in part to existing dry climatic conditionsdry climatic conditions

2424

Table (2) Distribution of allergen antibodies in rhinitis Table (2) Distribution of allergen antibodies in rhinitis patients.patients.

Allergen(antigen system)

AllergenAntibodies No.

AllergenAntibodies (%)

AntibodiesSystem (%)

Pollens (Aeroallergens)AlderBirchHazel

GrassesRye

MugwortPlantain

Oak

1111101311

85

11

9.49.48.5

11.19.46.84.39.4

68.3

Animal epithelia danderCat

Horse

Dog

Guinea pig

Golden Hamster

Rabbit

114

1012

-

9.43.48.50.91.7

-

23.9

2525

House dust Mites

Derm. pteronyssinus

Derm. farinae

2

5

1.7

4.3

6.0

Mould

Alternaria alternate

Pencillium notatum

Cladosporium hebarum

Aspergilus fumigatus

- -

11

--

0.90.9

1.8

Total 117 100 100

Allergen(antigen system)

AllergenAntibodies No.

AllergenAntibodies (%)

AntibodiesSystem (%)

2626

Figure ( ) Diagram showing the overlapping of Figure ( ) Diagram showing the overlapping of sensitization to combination of allergens (%) sensitization to combination of allergens (%)

among patients with allergic rhinitisamong patients with allergic rhinitis

2727

Allergic patients are not only allergic to Allergic patients are not only allergic to one sole type of allergen since many of one sole type of allergen since many of them will display sensitization to a them will display sensitization to a combination of allergens . combination of allergens .

The largest subset of patients display a The largest subset of patients display a combination of sensitization to both pollen combination of sensitization to both pollen and danderand dander

2828

Table (3) Patients with one or multiple allergen Table (3) Patients with one or multiple allergen antibodies developedantibodies developed

No. of allergenAntibodies developed

No. of patientsand percentage

Sensitized patients (Percentage)

1 06 (15.8%) 24 %

2 01 (2.6%) 4 %

3 03 (7.9%) 12 %

4 02 (5.3%) 8 %

5 03 (7.9%) 12 %

6 03 (7.9%) 12 %

7 01 (2.6%) 4 %

8 04 (10.5%) 16 %

9 01 (2.6%) 4 %

11 01 (2.6%) 4 %

Total 65.1 100

2929

In most studies the prevalence of seasonal allergic In most studies the prevalence of seasonal allergic rhinitis is significantly higher than perennial rhinitis is significantly higher than perennial allergic rhinitis , and range from 4.5 % to 38.3 % allergic rhinitis , and range from 4.5 % to 38.3 % (Charpin et al 1993; Dotterud et al 1994) . (Charpin et al 1993; Dotterud et al 1994) .

In Finland the prevalence of allergic rhinitis is In Finland the prevalence of allergic rhinitis is around 14% (Pekkanen et al, 1997).around 14% (Pekkanen et al, 1997).

in Australia 27% ( Woolcock et al 2001), while in in Australia 27% ( Woolcock et al 2001), while in India 20-30% of the general population suffers India 20-30% of the general population suffers from allergic rhinitis (Anonymous, 2000). from allergic rhinitis (Anonymous, 2000).

In the United States allergic rhinitis seems to be In the United States allergic rhinitis seems to be exceedingly common where 9-40% of the exceedingly common where 9-40% of the population may have some form of allergic population may have some form of allergic rhinitis at anytime of the yearrhinitis at anytime of the year

3030

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

3131

In a related study in Ankara, Turkey, grass pollen In a related study in Ankara, Turkey, grass pollen were found to be the major allergens in a study by were found to be the major allergens in a study by Sener et all (2003). Sener et all (2003).

In Kuwait, higher sensitization rates were seen among In Kuwait, higher sensitization rates were seen among pollen belonging to plants which were imported pollen belonging to plants which were imported from other countries for shading purposes or for from other countries for shading purposes or for binding sand, like binding sand, like ChenopediumChenopedium and and BermudaBermuda grass (Dowalsan et al, 2000).grass (Dowalsan et al, 2000).

In most European and North American countries In most European and North American countries allergens with the highest sensitization rates allergens with the highest sensitization rates among patients with nasal symptoms were also among patients with nasal symptoms were also pollen/aeroallergens followed by house dust mites pollen/aeroallergens followed by house dust mites and cat dander and cat dander

3232

HDM were reported to have the highest HDM were reported to have the highest rate of sensitization among patients with rate of sensitization among patients with allergic rhinitis in allergic rhinitis in ThailandThailand (Pumhirum et (Pumhirum et al, 1997), al, 1997), SingaporeSingapore (Chow et al, 1999) (Chow et al, 1999) and in and in TaiwanTaiwan especially among especially among asthmatic patients (Tsai et al, 1998). asthmatic patients (Tsai et al, 1998).

3333

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

PrevalencePrevalence AgeAge CountryCountry YearYear

24.0%24.0% 16-6516-65 UKUK 19911991

62.5%62.5% H. SchoolH. School TurkeyTurkey 19941994

51.0%51.0% H. schoolH. school TurkeyTurkey 19961996

27.6%27.6% 6-76-7 SingaporeSingapore 19941994

41.5%41.5% 12-1512-15 SingaporeSingapore 19941994

22.0%22.0% 7-177-17 DenmarkDenmark 20002000

15.9%15.9% 20-4420-44 ItalyItaly 20022002

26.3%26.3% U studentU student BangkokBangkok 20022002

3434

Prevalence of Rhinitis in UKPrevalence of Rhinitis in UK

PrevalencePrevalence AgeAge AuthorAuthor YearYear

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

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

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

49.5%49.5% WorkersWorkers Tong et al.Tong et al. 20012001

3535

DiscussionDiscussion This study clearly suggests that pollen This study clearly suggests that pollen

constitute the most important group of constitute the most important group of sensitizing allergens in patients with allergic sensitizing allergens in patients with allergic rhinitis in this region with as many as 68.3% rhinitis in this region with as many as 68.3% of all positive cases sensitized to at least of all positive cases sensitized to at least one pollen.one pollen.

In this study IgE - mediated sensitization to In this study IgE - mediated sensitization to fungal allergen was rare in allergic rhinitis fungal allergen was rare in allergic rhinitis patients which means that people in a patients which means that people in a certain locality had less exposure to mould certain locality had less exposure to mould allergensallergens

3636

Pet ownership is not popular in Saudi Arabia Pet ownership is not popular in Saudi Arabia and detailed studies on animal dander and detailed studies on animal dander sensitivity are lacking. Pet ownership is sensitivity are lacking. Pet ownership is undoubtedly a more common practice in undoubtedly a more common practice in other parts of the non-Moslem world, such as other parts of the non-Moslem world, such as in Europe and America, where more and more in Europe and America, where more and more people are choosing a solitary existence, people are choosing a solitary existence, accompanied only by a pet animal at home.accompanied only by a pet animal at home.

Allergen calendars could be a helpful guide in Allergen calendars could be a helpful guide in determining probable provocative factors determining probable provocative factors among allergic rhinitis patients presenting with among allergic rhinitis patients presenting with a history of sensitization . Spring heralds an a history of sensitization . Spring heralds an epidemiologic peak in the number of cases epidemiologic peak in the number of cases yearly . yearly .

3737

ConclusionsConclusions

1.1. The results of this study show that even in warm climates The results of this study show that even in warm climates pollen , animal dander and HDM allergens may be important pollen , animal dander and HDM allergens may be important sensitizing allergens . sensitizing allergens .

2.2. Pollens of local horticultural plants are the main sensitizing Pollens of local horticultural plants are the main sensitizing allergens among patients with allergic rhinitis in the locality allergens among patients with allergic rhinitis in the locality studied, studied, which may play a role in the pathogenesis of allergic respiratory diseases and should therefore be considered important factors in the management of patients affected in regions presenting with a generally warm dry climate most of the year .

3.3. The practice of greening the country seems to contribute to The practice of greening the country seems to contribute to increased rates of allergic sensitization of persons prone to increased rates of allergic sensitization of persons prone to allergic rhinitis.allergic rhinitis.

4. Subtle changes in social practices, like pet ownership, increasing mobilisation and introduction of new potentially allergen.

5. The results of this study are mostly consistent with the results of other studies made in other parts of the world, with some variations due to differences in environmental conditions and social practices .

6.6. Local environmental and genetic factors are probably involved Local environmental and genetic factors are probably involved in the pathogenesis of the disease .in the pathogenesis of the disease .

3838

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 * Antihistamines.* Antihistamines.

* Topical corticosteroids.* Topical corticosteroids.

* Anticholinergics.* Anticholinergics.

* Decongestants* Decongestants

Immunotherapy-injection Immunotherapy-injection

SublingualSublingual

3939

TreatmentTreatment

SymptomsSymptoms Symptomatic treatmentsSymptomatic treatments

Nasal obstruction Nasal obstruction due to nonallergic due to nonallergic rhinitisrhinitis

* Azelastine HCL nasal * Azelastine HCL nasal sprayspray

* Oral decongestant* Oral decongestant

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

* Increase water intake.* Increase water intake.

* Nasal saline irrigation.* Nasal saline irrigation.

* Humidity to bedroom.* Humidity to bedroom.

Bilateral anterior Bilateral anterior rhinorrhearhinorrhea

* Intranasal cortisteroid.* Intranasal cortisteroid.

* Atrovent spray.* Atrovent spray.

* Nasal saline* Nasal saline