Severity and duration of allergic conjunctivitis: are they associated with severity and duration of allergic rhinitis and asthma?

Summary: Objective. The association of allergic conjunctivitis (AC) with rhinitis and/or asthma is poorly understood. The objective of this study was to apply the Consensus Document for Allergic Conjunctivitis (DECA) criteria for the classification of AC to a population of patients with AC to assess the association between the severity and duration of AC and rhinitis and/or asthma. Methods. Patients with ocular symptoms of AC who participated in the 'Alergológica 2015' study were included. The demographics, classification according to the DECA criteria, etiology, and comorbidities were evaluated by age groups (less or equal than 14 and greater than 14 years). Results. A total of 2,914 patients (age range, 1-90 years) were included in the "Alergológica 2015" study. Of these, 965 patients (33.1%) were diagnosed with AC (77.5% > 14 years). AC was classified as severe, moderate, or mild in 1.8%, 46.4%, and 51.8%, respectively; and as intermittent or persistent in 51.6% and 48.4% of the patients. AC alone occurred in 4% of patients. AC was mainly associated with rhinitis (88.4%), asthma (38.2%), food allergy (8.3%) and atopic dermatitis (3.5%). In allergic respiratory disease rhinitis preceded AC and asthma developed later. The severity and duration of AC was significantly associated with severity and duration of rhinitis (p less than 0.001 for both age groups) and asthma (p less than 0.001 only in adults). Conclusions. The application of the new DECA classification for AC reveals a direct relationship between AC, rhinitis and asthma respect to severity and duration. These relationships suggest that AC should be considered an integral part of the "one airway, one disease" hypothesis.

Estimate of the total costs of allergic rhinitis in specialized care based on real-world data: the FERIN Study.

BACKGROUND: Despite the socioeconomic importance of allergic rhinitis (AR), very few prospective studies have been performed under conditions of clinical practice and with a sufficiently long observation period outside the clinical trial scenario. We prospectively estimated the direct and indirect costs of AR in patients attending specialized clinics in Spain. METHODS: Patients were recruited at random from allergy outpatient clinics in 101 health centers throughout Spain over 12 months. We performed a multicenter, observational, prospective study under conditions of clinical practice. We analyzed direct costs from a funder perspective (healthcare costs) and from a societal perspective (healthcare and non-healthcare costs). Indirect costs (absenteeism and presenteeism [productivity lost in the workplace]) were also calculated. The cost of treating conjunctivitis was evaluated alongside that of AR. RESULTS: The total mean cost of AR per patient-year (n = 498) was €2326.70 (direct, €553.80; indirect, €1772.90). Direct costs were significantly higher in women (€600.34 vs €484.46, P = 0.02). Total costs for intermittent AR were significantly lower than for persistent AR (€1484.98 vs €2655.86, P < 0.001). Total indirect costs reached €1772.90 (presenteeism, €1682.71; absenteeism, €90.19). The direct costs of AR in patients with intermittent asthma (€507.35) were lower than in patients with mild-persistent asthma (€719.07) and moderate-persistent asthma (€798.71) (P = 0.006). CONCLUSIONS: The total cost of AR for society is considerable. Greater frequency of symptoms and more severe AR are associated with higher costs. Indirect costs are almost threefold direct costs, especially in presenteeism. A reduction in presenteeism would generate considerable savings for society.

Relationship between respiratory and food allergy and evaluation of preventive measures.

Food allergy and respiratory allergy are two frequently associated diseases and with an increasing prevalence. Several reports show the presence of respiratory symptoms in patients with food allergy, while certain foods may be related to the development or exacerbation of allergic rhinitis and asthma. The present update focuses on this relationship, revealing a pathogenic and clinical association between food and respiratory allergy. This association is even more intense when the food hypersensitivity is persistent or starts in the early years of life. Food allergy usually precedes respiratory allergy and may be a risk factor for allergic rhinitis and asthma, becoming a relevant clinical marker for severe atopic asthma. Furthermore, the presence of co-existing asthma may enhance life-threatening symptoms occurring during a food allergic reaction. Recommendations for dietary restrictions during pregnancy and breastfeeding to prevent the development of respiratory allergy are controversial and not supported by consistent scientific data. Current recommendations from medical societies propose exclusive breastfeeding during the first four months of life, with the introduction of solid food in the fourth to the seventh month period of life. A delayed introduction of solid food after this period may increase the risk of developing subsequent allergic conditions. Further studies are encouraged to avoid unjustified recommendations involving useless dietary restrictions.

Clinical Management and Use of Health Care Resources in the Treatment of Nasal Polyposis in Spanish Allergy Centers: The POLAR Study.

BACKGROUND: Nasal polyposis (NP) is a chronic inflammatory disease that constitutes a major health problem with significant comorbidities and a considerable associated socioeconomic burden. OBJECTIVE: To describe the clinical features and management of patients with NP attending Spanish allergy centers, the use of health care resources, and the degree of compliance with the diagnostic and therapeutic recommendations of the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS). METHODS: We performed a multicenter, observational, and cross-sectional epidemiologic study of 671 patients consulting for NP in 67 Spanish allergy departments. We used sociodemographic and clinical questionnaires to evaluate clinical characteristics, use of health care resources, diagnostic methods, and treatment administered. RESULTS: NP was closely associated with asthma (66%), allergic rhinitis (45.9%), and hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) (26%). Atopy was present in the 50% of cases, with Dermatophagoides pteronyssinus as the most frequent sensitizing allergen. Eleven percent of NP patients visited the emergency department during the previous year, and more than 58% used primary care, allergy, or otorhinolaryngology services. The most frequently used diagnostic tests were skin prick tests (93.6%) and anterior rhinoscopy (79.4%). Intranasal corticosteroids were the drug class most frequently prescribed by allergists (74.6%). Specific immunotherapy was prescribed in 21% of patients. CONCLUSIONS: NP is a chronic inflammatory disease that generates considerable use of health care resources. The close association with atopy, asthma, and NSAID hypersensitivity highlights the usefulness of an allergy workup in all patients with NP. Analysis of the clinical management of NP by allergists in Spain revealed a high degree of compliance with EPOS diagnostic and therapeutic recommendations.

Nasal Hyperreactivity: Nonspecific Nasal Provocation Tests. Review by the Rhinoconjunctivitis Committee of the Spanish Society of Allergy and Clinical Immunology.

Nasal hyperreactivity is the abnormal reaction of nasal tissue to a stimulus that is innocuous to most people. This response is caused by dysregulation of the autonomic nervous system at various levels of the nasal autonomic reflex arc. Various stimuli (methacholine, histamine, adenosine 5'-monophosphate, cold air, mannitol, rapsaicin, phentolamine, and distilled water) have been used in an attempt to find the test that most reliably differentiates between healthy individuals and patients and also between different types of rhinitis. Despite the small number of publications available, in the present review, we provide an update on current nonspecific nasal provocation techniques. The studies published to date are not comparable: the stimuli applied act through different mechanisms and are used to assess different pathways, and the methodologies differ in terms of selection of participants, concentrations used, and assessment of response (criteria for positivity). Given the limited use of nonspecific nasal provocation tests in routine clinical practice, we believe that more studies are warranted to address the research issues we present at the end of the present review, for example, the need to standardize the methodology for each test or even the clinical benefits of knowing whether or not a patient has nasal hyperreactivity.

Consensus document on allergic conjunctivitis (DECA).

Allergic conjunctivitis (AC) is an inflammatory disease of the conjunctiva caused mainly by an IgE-mediated mechanism. It is the most common type of ocular allergy. Despite being the most benign form of conjunctivitis, AC has a considerable effect on patient quality of life, reduces work productivity, and increases health care costs. No consensus has been reached on its classification, diagnosis, or treatment. Consequently, the literature provides little information on its natural history, epidemiological data are scarce, and it is often difficult to ascertain its true morbidity. The main objective of the Consensus Document on Allergic Conjunctivitis (Documento dE Consenso sobre Conjuntivitis Alérgica [DECA]), which was drafted by an expert panel from the Spanish Society of Allergology and Spanish Society of Ophthalmology, was to reach agreement on basic criteria that could prove useful for both specialists and primary care physicians and facilitate the diagnosis, classification, and treatment of AC. This document is the first of its kind to describe and analyze aspects of AC that could make it possible to control symptoms.

Allergen-specific nasal provocation testing: review by the rhinoconjunctivitis committee of the Spanish Society of Allergy and Clinical Immunology.

Specific nasal provocation testing (NPT) consists of eliciting a response from the nasal mucosa by controlled exposure to allergens. It is indicated in the diagnostic confirmation of allergic rhinitis and when discrepancies arise or difficulties exist in the assessment of a patient's medical history and the results of skin and/or serological tests. The technique is also applied to evaluate sensitivity to the allergen, the efficacy and safety profile of treatment, and in research on the pathophysiological mechanisms of nasal response to allergens. NPT also provides information on the etiology of occupational respiratory diseases of allergic origin. Although there have been many studies and publications on the use and standardization of bronchial provocation tests with allergen, few analyze specific NPT. In this review, the Rhinoconjunctivitis Committee of the Spanish Society of Allergy and Clinical Immunology discuss the methodology, monitoring, and assessment of allergen-specific NPT in order to provide a practical and up-to-date review of the technique.

Rhinitis and its association with asthma in patients under 14 years of age treated in allergy departments in Spain.

BACKGROUND: Allergic rhinitis is the most frequent chronic allergic disease in children, and may be an important risk factor for the subsequent development of asthma. OBJECTIVE: To describe the characteristics of patients younger than 14 years of age presenting with rhinitis and the possible association with asthma. METHODS: We carried out a prospective, observational, descriptive, cross-sectional epidemiologic study (Alergológica 2005) of 917 patients under the age of 14 consulting for the first time in allergy departments in Spain. RESULTS: Rhinitis was diagnosed in 42.5% of the children. The association between asthma and rhinitis was significantly higher in children than in adults (44.9% vs 35.5%; P<.05). Time from onset of rhinitis was significantly associated with the development of asthma (2.97 vs 2.06 years; P<.0001). Allergy was the most frequent cause of rhinitis in children with and without asthma. Allergy to epithelia and fungi was more frequent in children with rhinitis and asthma than in children with rhinitis alone. We found no differences in the frequency of treatment with immunotherapy between children with and without asthma. CONCLUSION: Rhinitis was frequently associated with asthma in children consulting for the first time at allergy departments. Time since onset of rhinitis and sensitivity to epithelia and fungi were associated with the development of asthma.

IgE reactivity to profilin in Platanus acerifolia pollen-sensitized subjects with plant-derived food allergy.

BACKGROUND: The presence of profilin-specific IgE antibodies is a cause of cross-reactivity between botanically-unrelated allergen sources. Recently, the association between Platanus acerifolia pollinosis and plant-derived food allergy has been described. The aim of this study was to ascertain whether the P. acerifolia profilin is involved in such cross-reactivity. METHODS: Twenty-three patients suffering from Platanus acerifolia pollinosis and plant-derived food allergy were evaluated in an allergy department. Specific IgE levels to P. acerifolia pollen, P. acerifolia profilin and food extracts were measured. Molecular masses of IgE-binding proteins were calculated by Western blotting and cross-reactivity studies among P. acerifolia profilin and different food extracts were evaluated by Enzyme AllergoSorbent Test (EAST)-inhibition assays. Also, EAST-inhibition assays with the two known P. acerifolia allergens, Pla a 1 and Pla a 2, were performed. RESULTS: Surprisingly, a high IgE-binding prevalence (90%) of P. acerifolia profilin was found. EAST-inhibition showed high inhibition values when Platanus acerifolia pollen extract was used as free phase and plant-derived food extracts as solid phase, whereas the other way round showed low inhibition values. IgE reactivity to profilin was studied using a pool of patient sera, by EAST-inhibition assays with hazelnut, apple peel, peanut, chickpea and peanut extracts as solid phase and no inhibition was obtained when P. acerifolia profilin was used as inhibitor phase. The same results were obtained when purified Pla a 1 and Pla a 2 were also used as inhibitor phase. CONCLUSIONS: The clinical association observed between Platanus acerifolia pollen and plant-derived food could be explained by the in vitro IgE cross-reactivity detected by EAST-inhibition. However, it appears that neither P. acerifolia profilin nor the two major allergens described (Pla a 1 and Pla a 2) can explain such a strong cross-reactivity.

[Exercise-induced anaphylaxis syndrome]. / Síndrome de anafilaxia inducida por ejercicio.

In the last two decades a growing incidence of a peculiar form of anaphylaxis that only occurs while carrying out physical exercise has been observed. Within the exercise-induced anaphylaxis syndrome two well differentiated clinical forms are included: systemic cholinergic urticaria and exercise-induced anaphylaxis in the strict sense which can be shown by a classic form or a variant form, more uncommon and with manifestations similar to cholinergic urticaria. Postprandial or food-dependent exercise-induced anaphylaxis is a frequently identified subtype of these last cases. It can be due to an asymptomatic food allergy manifested through physical effort, although in many occasions it is not possible to find a responsible allergen. The diagnosis is settled on the clinical history and specific tests with food allergens. It can be necessary to perform an exercise challenge test with and without previous ingestion. The treatment is preventive and it is based on avoiding the food or the food allergen some hours before the exercise. When it does not depend on foods it is used a prophylactic pharmacotherapy with antihistamines, cromones or sodium bicarbonate. The patient should be well educated on the use of epinephrine in the event of new reactions.

[Treatment with nebulized lidocaine in steroid-dependent asthma]. / Tratamiento con lidocaína nebulizada del asma corticodependiente.

BACKGROUND: The management of glucocorticoid dependent and resistant asthma encompasses a group of problems, affecting as much control of clinical symptoms as the onset of adverse effects to prolonged use of steroids. MATERIALS AND METHODS: Woman 52 years old, steroid dependent asthma fifteen years ago. She has important adverse effects in consequence of the use of systemic glucocorticoids. The employment of methotrexate attained decrease in the dosage of steroids temporarily. The worsening of the clinical situation and deterioration of secondary effects by use of steroids necessitated treatment with nebulized lidocaine. A 2% solution to initial dosage was administered three times daily. The maximal dosage needed was 80 mg three times daily. RESULTS: After three months of lidocaine treatment, the patient was able to reduce oral steroids eventually discontinuing these drugs, and the effects secondary to exogenous hypercortisolism disappeared. Moreover, an improvement in clinical symptoms and quality of life was observed with stability in the pulmonary function. CONCLUSIONS: The use of nebulized lidocaine could be useful and provide alternatives in patients with severe asthma.

Anaphylactic reaction to young garlic.

BACKGROUND: Garlic is well known to cause contact dermatitis and asthma. However, it is a very rare cause of food allergy. We present the case of a 23-year-old woman with previous history of allergy to pollen and dried fruit, and food-dependent, exercise-induced anaphylaxis for which no specific food could be identified as responsible, who experienced an anaphylactic reaction after eating young garlic. METHODS: Skin prick tests and specific IgE immunoassay with several pollens and foods were performed, as well as the prick-prick test with young garlic and SDS-PAGE followed by immunoblotting IgE to young garlic and other Liliaceae species, mustard, sesame, parsley, celery, hazelnut, almond, and pollen of birch and mugwort. RESULTS: Skin prick tests and specific IgE were mainly positive for grass, plane tree, and mugwort pollen; peanut; hazelnut; walnut; almond; and mustard. Prick-prick tests with young garlic and garlic were positive. Total IgE was 113 U/ml. SDS-PAGE immunoblotting showed IgE-binding bands at 12 kDa to young garlic, garlic, onion, and leek extracts. Similar bands could also be detected with mugwort pollen and hazelnut extract. CONCLUSIONS: We describe IgE-mediated reaction to young garlic in a patient sensitized to pollen and dried fruit.