Nasal Fluticasone Research Articles

0844 Isolated, Idiopathic Periodic Breathing in a School Age Child

Abstract Introduction Periodic breathing (PB) is a well described physiologic phenomenon of infancy and usually resolves with age1. PB that persists outside of infancy has been described in association with various pathologies such as Chiari malformation, upper airway anomalies and genetic abnormalities2. Isolated PB that persists past infancy is less well described, and there is little data to guide subsequent management and clinical decision making. Report of Cases: Here we present a case of a 12-year-old female with isolated PB on polysomnography (PSG). She initially presented to our sleep center clinic with complaints of snoring, gasping during sleep and daytime sleepiness. She had no significant past medical history and not on any sleep-modifying medications. PSG was ordered to evaluate for suspected obstructive sleep apnea. Total sleep time was 7.75 hours with a mildly reduced amount of REM (16% of total sleep time). She had a total of 4 minutes of central sleep apnea that met AASM criteria for periodic breathing. This occurred exclusively during transitions between N1 and N2 and was not associated with hypoxemia nor hypocapnia. The patient’s total apnea hypopnea index (AHI) was 2.97/hr, obstructive AHI 0.65/hr and central apnea index was 2.32/hr. Of note, this studywas not conducted at high altitude and was done in Houston (approximately 100 feet above sea level). Given the lack of significant sleep apnea, a conservative approach with nasal fluticasone and close follow-up was utilized. Conclusion Though rare, this case highlights the possibility of PB being an incidental finding of PSG in otherwise healthy, school aged children. The need for further research as to the significance of this incidental finding is also emphasized. Support (If Any) 1. MacLean, Joanna E., Dominic A. Fitzgerald, and Karen A. Waters. "Developmental changes in sleep and breathing across infancy and childhood." Paediatric respiratory reviews 16.4 (2015): 276-284.2. Ghirardo, Sergio, et al. "Central apnea and periodic breathing in children with underlying conditions." Journal of Sleep Research (2021): e13388.

Evaluation of knowledge and practice of primary health care physicians regarding medication prescribing during pregnancy in Jeddah, Saudi Arabia 2021

Background: Despite adequate guidelines that support medication prescribing during pregnancy, primary health care physicians’ practice in Saudi Arabia is still not assessed. Objectives: to assess knowledge and practice of physicians towards medication prescription during pregnancy and to determine obstacles in prescribing medications. Methods: Across-sectional study was done on of 168 PHC physicians in Jeddah, Saudi Arabia. A questionnaire was distributed to physicians online, including questions about their knowledge about medication prescribing (categories), reading sources, and practice. Results: 78.6% of PHC physicians faced obstacles in prescribing medication for pregnant women, where lack of time to read limited information about patient and treatment and pregnant women education level were the most common obstacles found. Amoxicillin (86.9%), Levothyroxine (75.6%), Methyldopa (73.8%), Calcium carbonate (71.4%), Nasal fluticasone (57.1%), and Penicillin G were the most commonly reported medications as being safe during pregnancy by participants (56.5%). Doxycycline (64.9%), methotrexate (63.7%), warfarin (54.2%), and statins were the most commonly reported unsafe medications. Participants aged 25-35 years had a significantly higher percentage of facing a lack of time to read as an obstacle in prescribing medication for pregnant women, whereas GPs had a significantly higher percentage of facing obstacles, such as the level of education of pregnant women, a lack of privacy in a PHC, and a lack of pregnancy education. Conclusion: There is insufficient awareness and practice of PHC physicians regarding medication prescribing during pregnancy. It is necessary to raise their awareness about the FDA guidelines. Keywords: knowledge, practice, PHC, medication, pregnancy, Jeddah

Effect of acupuncture therapy combined with fluticasone propionate in the treatment of persistent allergic rhinitis: study protocol for a randomized controlled trial

BackgroundAllergic rhinitis (AR) is an immunoglobulin E (IgE)-mediated inflammatory response.Persistent allergic rhinitis (PAR) is a subtype of AR, but the treatment of PAR is still a problem. Acupuncture is used as an alternative therapy for AR in clinical practice. The aim of this study is to evaluate the effectiveness of acupuncture therapy combined with fluticasone propionate nasal spray in comparison to fluticasone propionate nasal spray alone in the relief of symptoms for PAR.MethodsThis study is a multicenter, single-blind, randomized controlled trial. A total of 260 eligible patients will be randomly assigned into the treatment group or the control group. The treatment group will receive the nasal fluticasone propionate combined with acupuncture, and the control group will receive fluticasone propionate nasal spray alone for 6 weeks. The primary outcome is the change in the Reflective Total Nasal Symptom Score (rTNSS) from baseline to the end of treatment, and the Total Non Nasal Symptom Score (TNNSS), reflective total ocular symptom score (rTOSS), Rhinitis Quality of Life Questionnaire (RQLQ), use of antiallergic drugs, and the Rhinitis Control Assessment Test (RCAT) are used as secondary outcomes. The participants will be followed up for another 24 weeks after treatment.DiscussionThis clinical trial will be able to provide high level evidence on the acupuncture therapy combined with fluticasone propionate nasal spray in the treatment of PAR.Trial registrationISRCTN Registry, ID: ISRCTN44040506. Registered on 22 July 2020.

Comparison of C-reactive protein and Vitamin D3 level among Patients of Allergic Rhinitis while on treatment with either Nasal Fluticasone or Combination Therapy of Montelukast and Levocetirizine: A Randomized Control Study

We conducted the present study to compare the vitamin D3 status and C-reactive protein (CRP) among allergic rhinitis patients who were on treatment with either intranasal Fluticasone or oral Levocetrizine and Montelukast therapy. Material and Methods: The study was a prospective randomized, single blinded, comparative, parallel group study, with two intervention groups conducted at Civil Hospital Jogindernagar of Himachal Pradesh, India. A total of Fifty patients diagnosed with allergic rhinitis was randomly allocated to either Group A receiving oral Montelukast and Levocetrizine or Group B receiving Fluticasone propionate aqueous nasal spray and followed up for 6 weeks. Vitamin D status and C-reactive protein (CRP) after 6 weeks was taken as primary outcome variables. Results: Among Group A , Recovery at 6 weeks was occurred in 9 (36%) patients while in Group B Recovery at 6 weeks was occurred in 17(68 %) patients.(p value 0.046). There was statistically significant lower mean CRP level was found in group B as compared to Group A (p value 0.003). Although, lower mean Vit D3 level was found in group B as compared to Group A but this difference was not found to be statistically significant. (p value 0.218). Although, lower mean CRP and higher mean Vit D3 level was found in recovered patients in group A as compared to who were not recovered but this difference was not found to be statistically significant(p value 0.198 and 0.324 respectively). Similarly,higher mean CRP and Vit D3 level was found in recovered patients in group B as compared to who were not recovered but this difference was not found to be statistically significant.( p value 0.804 andp value 0.418). Similarly ,in recovered patients there was no statistical significant difference in mean CRP and Vit D3 level(P value 0.9536 and 0.2486 respectively) in both groups, although the mean CRP and Vit D3 level were higher in Group A as compared to group B. But in non recovered patients, the mean CRP level was statistically higher in Group A as compared to group B(P value0.0029) while there was no statistical significant difference in Vit D3 level in both groups.(p value-0.8919). Conclusion: Study concluded that there was no statistical significant difference in mean Vitamin D3 and CRP levels in both groups as well as there was no significant association between Vitamin D3 and CRP levels and recovery status of patients in both groups.

Effect of nasal fluticasone exhalation delivery system on Eustachian tube dysfunction.

Effect of nasal fluticasone exhalation delivery system on Eustachian tube dysfunction.

S3431 An Odd Place for Acne: Ectopic Esophageal Sebaceous Glands

INTRODUCTION: Sebaceous glands are typically found on the skin, providing lubrication to the skin and hair follicles. These glands are generally clustered on the face and scalp with fewer being found on the remaining skin surface. Esophageal sebaceous glands are extremely rare. As of 2017, less than 25 case reports had been published on this entity. Although rare and therefore not fully understood, esophageal sebaceous glands have not been linked to any attributable symptoms or risk or cancer. The following is a case of a patient evaluated for chronic cough who was ultimately found to have sebaceous glands in his esophagus. CASE DESCRIPTION/METHODS: A 63-year-old man was seen in gastroenterology clinic for evaluation of chronic cough and globus sensation. An esophagogastroduodenoscopy (EGD) displayed yellow, plaque-like material extending from proximal to distal esophagus (images A and B). These lesions could not be removed with lavage and were subsequently biopsied. The biopsy demonstrated a collection of round cohesive cells with cleared out cytoplasm and small centrally located nuclei arranged in an acinar configuration, consistent with ectopic sebaceous glands (image C). These glands are located within the lamina propria underlying a normal appearing stratified squamous cell epithelium. The patient also had esophageal pH testing showing a normal DeMeester score. Patient was treated with nasal fluticasone with improvement in his presenting symptoms. Therefore, symptoms were attributed to post-nasal drip, rather than the ectopic sebaceous glands. DISCUSSION: Ectopic esophageal sebaceous glands are a rare, benign finding. There is no known malignant potential to these lesions and no known attributable symptoms. Although rare and benign, endoscopists should have a familiarity with the appearance of ectopic esophageal sebaceous glands in order to distinguish them from other, non-benign lesions (such as squamous cell carcinoma) and potentially avoid unnecessary biopsies or other invasive testing.Figure 1.: Esophagus with sebaceous glands.Figure 2.: Esophagus with sebaceous glands.Figure 3.: Pathology slide of sebaceous glands in the esophagus.

EXERCISE INDUCED RHINITIS: A PREVALENT BUT ELUSIVE DISEASE

Introduction Exercise induced rhinitis is defined as inflammation of the nasal passages leading to rhinorrhea, sneezing, congestion or nasal itching related to physical activity. Although abundant research exists regarding exercise induced asthma, urticaria, and anaphylaxis, as well as allergic rhinitis, little is understood regarding exercise induced rhinitis. Exercise induced rhinitis has been displayed in indoor and outdoor athletes with and without nasal allergy. Similarities exist between the nasal mucosa and the bronchial airways, suggesting similar mechanisms of inflammation between exercise induced asthma and rhinitis. These include airway dehydration, hyperpnoea, fluid hyperosmolarity, neutrophilic inflammation, histamine release and mast cell degranulation. Case Description This case involved a 37-year-old female who presented with rhinitis during exercise. Her symptoms included nasal congestion and discharge, sneezing, and itchy nose, and exam revealed edematous nasal turbinates. Her symptoms were only mildly improved with daily oral Cetirizine and nasal Fluticasone. Allergy testing revealed IgE of 13kU/L (Ref: <=214kU/L), with environmental and food allergens showing no significant elevations in specific IgE levels, suggesting a non-allergic etiology. She was started on a trial of nasal Azelastine to be used prior to exercise, which provided relief of symptoms. Discussion Currently, no standardized method of diagnosis or treatment of exercise induced rhinitis exists. Suggested treatment strategies include intranasal corticosteroids, decongestants, and antihistamines, however, each have side effects that can interfere with exercise. Further research is indicated to explore the mechanism, evaluation, and treatment of exercise induced rhinitis as a distinct entity to ensure the safety and success of affected athletes. Exercise induced rhinitis is defined as inflammation of the nasal passages leading to rhinorrhea, sneezing, congestion or nasal itching related to physical activity. Although abundant research exists regarding exercise induced asthma, urticaria, and anaphylaxis, as well as allergic rhinitis, little is understood regarding exercise induced rhinitis. Exercise induced rhinitis has been displayed in indoor and outdoor athletes with and without nasal allergy. Similarities exist between the nasal mucosa and the bronchial airways, suggesting similar mechanisms of inflammation between exercise induced asthma and rhinitis. These include airway dehydration, hyperpnoea, fluid hyperosmolarity, neutrophilic inflammation, histamine release and mast cell degranulation. This case involved a 37-year-old female who presented with rhinitis during exercise. Her symptoms included nasal congestion and discharge, sneezing, and itchy nose, and exam revealed edematous nasal turbinates. Her symptoms were only mildly improved with daily oral Cetirizine and nasal Fluticasone. Allergy testing revealed IgE of 13kU/L (Ref: <=214kU/L), with environmental and food allergens showing no significant elevations in specific IgE levels, suggesting a non-allergic etiology. She was started on a trial of nasal Azelastine to be used prior to exercise, which provided relief of symptoms. Currently, no standardized method of diagnosis or treatment of exercise induced rhinitis exists. Suggested treatment strategies include intranasal corticosteroids, decongestants, and antihistamines, however, each have side effects that can interfere with exercise. Further research is indicated to explore the mechanism, evaluation, and treatment of exercise induced rhinitis as a distinct entity to ensure the safety and success of affected athletes.

P378 A case of the nerves tiotropium for treatment of resistant anaphylaxis with vocal cord dysfunction

A 17-year-old girl with an allergy to house dust mites presented with recurrent and frequent episodes (2-3 per week) of acute lip/tongue angioedema, diffuse rash, and respiratory distress with inspiratory stridor. Most episodes were triggered by exposures to scents from perfumes and soaps. Despite prophylactic treatment with inhaled and nasal fluticasone propionate and an oral regimen of daily diphenhydramine, cetirizine, and hydroxyzine, as well as on demand intramuscular epinephrine and multiple courses of oral steroids, she experienced over fifteen episodes requiring emergency room visits and four hospital admissions. She was diagnosed with Vocal Cord Dysfunction (VCD) as an outpatient by speech pathology using nasal laryngoscopy and was taught breathing and relaxation exercises. Her symptoms persisted and she was started on inhaled tiotropium at 5mcg daily. Since receiving tiotropium and maintenance H1 blockers, she had only one episode of anaphylaxis without respiratory symptoms, resolving with self-administration of oral diphenhydramine and intramuscular epinephrine.

Nasal inflammation and its response to local glucocorticoid regular treatment in patients with persistent non-allergic rhinitis: a pilot study.

BackgroundThe pathogenesis of non-allergic rhinitis (NAR) is still largely unknown. Furthermore, it is unclear whether there is a correlation between the effect of nasal glucocorticoids on nasal inflammation and on nasal symptoms and quality of life.MethodsIn this pilot study we recruited 12 healthy subjects and 24 patients with recently diagnosed persistent NAR [12 untreated and 12 under regular treatment with nasal fluticasone furoate (two sprays of 27.5 μg each in each nostril once daily, total daily dose = 110 μg) for at least 20 days]. Each subject filled a mini rhinoconjunctivitis quality of life questionnaire (mini RQLQ). Nasal scrapings were obtained from each subject and used to prepare slides for Diff-Quik and immunocytochemical staining for inflammatory and epithelial cells count, MUC5AC expression and the general pro-inflammatory transcription factor nuclear factor kB (NF-kB) activation.ResultsThe nasal score of the mini RQLQ, the number of nasal inflammatory cells (neutrophils, eosinophils) and the number of goblet cells are significantly higher in untreated patients with persistent NAR compared with control subjects and treated NAR patients. The percentage of MUC5AC+ nasal epithelial cells is significantly increased in untreated patients with persistent NAR compared with the control subjects (41.8 ± 6.4 vs 22.3 ± 4.8, respectively; p = 0.0403) without significant differences between control subjects and patients with persistent NAR on regular fluticasone furoate treatment (33.9 ± 5.0 %; p = 0.0604) nor between the 2 groups of persistent NAR subjects (p = 0.3260). The number of cytosolic and/or nuclear p65+ nasal epithelial and inflammatory cells was not significantly different between the three groups.ConclusionsPatients with persistent untreated NAR, compared with normal control subjects and patients with persistent NAR under regular treatment with nasal fluticasone furoate by at least 20 days, have more nasal symptoms, worst quality of life and an increased number of nasal inflammatory cells (neutrophils, eosinophils), goblet cells and MUC5AC+ nasal epithelial cells. This nasal inflammation seems unrelated to NF-kB activation.

Effects of nasal corticosteroids on boosts of systemic allergen-specific IgE production induced by nasal allergen exposure.

BackgroundAllergen exposure via the respiratory tract and in particular via the nasal mucosa boosts systemic allergen-specific IgE production. Intranasal corticosteroids (INCS) represent a first line treatment of allergic rhinitis but their effects on this boost of allergen-specific IgE production are unclear.AimHere we aimed to determine in a double-blind, placebo-controlled study whether therapeutic doses of an INCS preparation, i.e., nasal fluticasone propionate, have effects on boosts of allergen-specific IgE following nasal allergen exposure.MethodsSubjects (n = 48) suffering from grass and birch pollen allergy were treated with daily fluticasone propionate or placebo nasal spray for four weeks. After two weeks of treatment, subjects underwent nasal provocation with either birch pollen allergen Bet v 1 or grass pollen allergen Phl p 5. Bet v 1 and Phl p 5-specific IgE, IgG1–4, IgM and IgA levels were measured in serum samples obtained at the time of provocation and one, two, four, six and eight weeks thereafter.ResultsNasal allergen provocation induced a median increase to 141.1% of serum IgE levels to allergens used for provocation but not to control allergens 4 weeks after provocation. There were no significant differences regarding the boosts of allergen-specific IgE between INCS- and placebo-treated subjects.ConclusionIn conclusion, the application of fluticasone propionate had no significant effects on the boosts of systemic allergen-specific IgE production following nasal allergen exposure.Trial Registrationhttp://clinicaltrials.gov/ NCT00755066

Efficacy of daily intranasal fluticasone propionate on ocular symptoms associated with seasonal allergic rhinitis

BackgroundAllergic rhinitis (AR) is an inflammatory condition of the nasal mucosa characterized by symptoms of nasal discharge, itching, sneezing, and congestion. Ocular symptoms are commonly associated with AR and include itching or burning, tearing or watering, and redness. Intranasal corticosteroids are a mainstay of treatment, and their effect on nasal symptoms is well described. ObjectiveTo demonstrate that a 14-day course of 200 μg/d of nasal fluticasone propionate is superior to placebo in relieving ocular symptoms associated with AR. MethodsThis was a randomized, double-blind, parallel group, multicenter study comparing 200 μg/d of fluticasone propionate with placebo in patients with seasonal allergic rhinitis. The primary end point was mean change from baseline in patient-rated reflective total ocular symptom score (rTOSS). Key secondary end points included mean change from baseline in the morning and evening rTOSS, end-of-treatment assessment of response, and effect on activities of daily living. The primary analysis was performed using analysis of covariance with a linear fixed-effects model. ResultsFluticasone was statistically significantly more efficacious in reducing the ocular symptoms of AR than placebo. The least squares mean difference in the change from baseline of rTOSS was −0.36 (P = .002). A statistically significant difference in mean change from baseline was observed in favor of fluticasone for morning and evening rTOSS. Significantly more patients taking fluticasone achieved an overall response compared with placebo. Fluticasone had a significantly greater effect on daily living activities and was well tolerated. ConclusionThis study supports the efficacy of fluticasone in treating ocular symptoms associated with AR. Trial Registrationclinicaltrials.gov Identifier: NCT01817790.

MP29-02 (Dymista®) – Eine neue Behandlungsoption für die allergische Rhinitis

Introduction: Recent developments in drug research in the indication allergic rhinitis (AR) include the development of new compounds as well as new formulations of substances with synergistic effects. IVIP29-02 (Dymista (R)) is a novel drug for AR treatment consisting of a new intranasal formulation of the antihistamine azelastine hydrochloride (AZE) and the nasal glucocorticoid fluticasone propionate (FP). Methods: Based on a literature review we summarise the results of several clinical trials regarding efficacy and safety of MP29-02 compared to AZE and FP monotherapy and placebo. Results: Compared to AZE, FP, and placebo, MP29-02 has demonstrated a superior efficacy in regard to nasal and ocular symptoms. Patients with moderate-to-severe seasonal allergic rhinitis (SAR) treated with MP29-02 showed an up to 7 days faster response of nasal symptoms than AZE and up to 5 days faster than FP treatment. Also, in patients with chronic rhinitis, MP29-02 significantly improved nasal symptoms compared to the FP therapy. Discussion and conclusion: MP29-02 represents a novel and promising combination for the treatment of AR with superior efficacy over current first line therapies.

Nasal corticosteroid treatment reduces substance P levels in tear fluid in allergic rhinoconjunctivitis

BackgroundThe mechanisms underlying conjunctival symptom reduction by nasal corticosteroids in allergic rhinoconjunctivitis are unknown. A naso-ocular reflex may be present. ObjectiveTo study the effects of nasal fluticasone furoate (FF) on conjunctival symptoms and substance P and histamine levels in tear fluid after nasal grass pollen provocation (GPP). MethodsA double-blind placebo-controlled study was performed in 26 grass pollen–allergic patients. A selective GPP was performed during the grass pollen season after 2 weeks of FF or placebo treatment. Nasal and conjunctival symptoms were scored using a visual analog scale (VAS), and tear fluid was collected for measuring substance P and histamine using an enzyme-linked immunosorbent assay. ResultsCompared with placebo, FF reduced conjunctival symptom scores during the pollen season (−1.75 [−2.75, 0.20] vs 0.0 [0.0, 0.0]; P = .01) and after GPP at 15 minutes (0.05 [−0.42, 1.52] vs 2.05 [0.62, 3.62]; P < .001) and 1 hour (−0.45 [−1.75, 0.1] vs 0.05 [−0.97, 1.85]; P < .01). Treatment with FF decreased substance P levels in tear fluid (44.11 [32.81, 61.02] vs 65.26 [48.62, 79.73] pg/mg protein; P = .0098). Histamine levels in tear fluid showed a GPP-induced increase in the placebo group (7.26 [3.12, 9.69] vs 5.71 [2.05, 7.00] ng/mg protein; P = .02), but not in the FF group (6.77 [3.43, 13.00] vs 5.24 [3.18, 7.06] ng/mg protein; P = .08). ConclusionFF nasal spray reduced conjunctival symptoms in grass pollen–allergic patients in parallel with lower substance P levels in tear fluid. These data help in understanding the reduction of conjunctival symptoms by intranasal anti-inflammatory therapy.

The effects of an anti–IL-13 mAb on cytokine levels and nasal symptoms following nasal allergen challenge

IL-13 is a key T(H)2 cytokine that is implicated in allergic responses. We evaluated the effects of an anti-IL-13-blocking antibody compared with placebo on repeated nasal allergen challenge responses in hay fever patients out of season. We performed a parallel group double-blind study of anti-IL-13 (single dose, 6 mg/kg intravenously, n= 16) and placebo (n= 15), with an additional open label group given a topical nasal corticosteroid (n= 5). Subjects received intranasal timothy grass pollen (Phleum pratense P5 allergen), and serial samples of nasal mucosal lining fluid were taken by using synthetic absorptive matrix and by nasal lavage. Administration of anti-IL-13 on day 1 resulted in a significant decrease in IL-13 levels in synthetic absorptive matrix eluates compared with placebo (area under the curve 0-8 hours, change from baseline) during the late phase after nasal allergen challenge on day 5 (P< .05) and day 7 (P< .01). There were no apparent effects of anti-IL-13 treatment on nasal lavage eosinophil numbers or total nasal symptom scores versus placebo. However, in a subgroup with high late-phase IL-13 levels at screening, there was a trend for a decrease in total nasal symptom scores after nasal allergen challenge on day 5, when compared with subjects with low IL-13 levels (P< .10). Nasal fluticasone caused suppression of IL-13 (P< .05 on day 5) as well as IL-5 (P< .01 on day 5) levels in the late phase compared with placebo. Anti-IL-13 had specific pharmacodynamic action in this nasal allergen challenge model, causing profound inhibition of nasal lining fluid IL-13 responses. In addition, there was a possible effect of anti-IL-13 treatment on total nasal symptom scores in a subgroup with high late-phase nasal IL-13 levels at screening.

The role of inhaled and/or nasal corticosteroids on the bronchodilator response

PurposeTo compare the profiles of the bronchodilator response (BDR) among children with asthma and/or allergic rhinitis (AR) and to determine whether BDR in these children is reduced by treatment with inhaled and/or nasal corticosteroid.MethodsSixty-eight children with asthma (mean age, 10.9 years), 45 children with comorbid asthma and AR (mean age, 10.5 years), and 44 children with AR alone (mean age, 10.2 years) were investigated. After a 2-week baseline period, all children were treated with inhaled fluticasone propionate (either 100 or 250 µg b.i.d., tailored to asthma severity) or nasal fluticasone propionate (one spray b.i.d. in each nostril) or both, according to the condition. Before and 2 weeks after starting treatment, all children were evaluated with spirometry and bronchodilator testing. BDR was calculated as a percent change from the forced expiratory volume in 1 second (FEV1) at baseline.ResultsThe mean BDR was 10.3% [95% confidence interval (CI) 8.3-12.4%] in children with asthma, 9.0% (95% CI 7.3-10.9%) in subjects with asthma and AR, and 5.0% (95% CI 4.1-5.9%) in children with AR alone (P<0.001). After treatment, the mean BDR was reduced to 5.2% (95% CI 4.2-6.3%) (P<0.001) in children with asthma and to 4.5% (95% CI 3.5-5.5%) (P<0.001) in children with asthma and AR. However, children with rhinitis showed no significant change in BDR after treatment, with the mean value being 4.7% (95% CI 3.7-5.8%) (P=0.597).ConclusionThe findings of this study imply that an elevated BDR in children with AR cannot be attributed to nasal inflammation alone and highlights the close relationship between the upper and lower airways.

Annular Patches and Plaques on the Scrotum and Buttocks—Quiz Case

A 36-year-old woman presented with a painful and pruritic eruption on both feet. She had a history of asthma, allergic rhinitis, and chronic sinusitis and had been treated atvarioustimeswithfexofenadinehydrochloride,mometasone furoate nasal spray, hydroxyzine hydrochloride, diphenhydramine hydrochloride, albuterol sulfate, montelukast sodium, fluticasone propionate, and salmeterol inhalation powder. She reported intermittent episodes of unilateral lower leg edema associated with pruritus, which had been treated with diphenhydramine in the past. The physical examination showed lower extremity swelling with retiform erythematous and hyperpigmented patches with central vesiculation limited to the dorsal feet (Figure1). Dorsalis pedis pulses were present. Initial laboratory studies revealed an elevated white blood cell (WBC) count of 14 900 cells/μL with 47% eosinophilia. The erythrocyte sedimentation rate was 92 mm/h, and the alkaline phosphatase level was 320 U/L. (To convert WBC count to cells 10 per liter, multiply by 0.001. To convert alkaline phosphatase to microkatals per liter, multiply by 0.0167.) A punch biopsy sample was taken from the right dorsal foot (Figure 2 and Figure 3) What is your diagnosis?

Advances in upper airway diseases and allergen immunotherapy

The purpose of this review is to highlight important articles on upper airway disease and immunotherapy that appeared in the Journal of Allergy and Clinical Immunology and elsewhere during 2005. In recent studies of tissue from patients with chronic hypertrophic eosinophilic sinusitis, increased leukotriene C4 synthase and 5-lipoxygenase activity and increased levels of cysteinyl leukotriene production were demonstrated that correlated with disease severity but not with whether the patient was aspirin sensitive. However, the cysteinyl leukotriene 1 receptor was increased in leukocytes in the sinus tissue only in those patients with aspirin sensitivity. Major basic protein, released by eosinophils into the mucus in the paranasal sinus lumen, was found to reach concentrations capable of damaging the sinus epithelium, predisposing to bacterial infections. Testing the hypothesis that chronic hypertrophic eosinophilic sinusitis represents a reaction to common fungi, a double-blind trial of intranasal instillation of amphotericin B was conducted. There were marginal but significant differences in favor of amphotericin B treatment for sinus mucosal thickening on the basis of computed tomography and the evidence of eosinophilic inflammation in the sinus mucus. The effectiveness of topical nasal corticosteroids for treatment of nasal polyps was confirmed in 2 large studies. Improvement in sleep quality and daytime drowsiness in patients with allergic rhinitis treated with nasal corticosteroids was reported to correlate with reduction in nasal obstruction. The statistical analysis behind studies that reported a decrease in asthma exacerbations with nasal corticosteroids or oral antihistamines has been questioned. It appears that the results of at least one of these studies are indeed too good to be true. Although caution is still indicated in administering immunotherapy to patients receiving beta-adrenergic blocking agents, the prohibition might not be absolute. A study in patients with Hymenoptera sensitivity given venom immunotherapy revealed no increase in serious adverse reactions to venom injections and no greater incidence of reactions to insect stings in those taking beta-blocking agents. Sublingual immunotherapy for 8 to 12 weeks in patients with hazelnut sensitivity significantly increased their tolerance to hazelnut in double-blind, placebo-controlled challenges while inducing increased IgG4 and IL-10 levels, indicating induction of regulatory T cells. There were a number of articles in the Journal of Allergy and Clinical Immunology in 2005 that addressed the entity of chronic hypertrophic eosinophilic sinusitis. In addition, an update of the "Practice parameters on sinusitis" was published. The major focus in allergen immunotherapy continues to be sublingual administration.

Intranasal steroid reduces exhaled bronchial cysteinyl leukotrienes in allergic patients

Allergic rhinitis (AR) precedes and is often associated with bronchial asthma. Indeed, local and systemic inflammations in both conditions are very similar. Cysteinyl-leukotrienes (cys-LTs) are generated during early- and late-phase allergic reactions and induce smooth-muscle contraction, microvascular leakage, and mucous hypersecretion. Cys-LTs are detected in exhaled breath condensate (EBC) of asthmatics and regardless of bronchial symptoms, they are also found in EBC of rhinitic patients. To evaluate cys-LTs in EBC of allergic patients and to assess the activity of nasal fluticasone propionate (FP) on EBC cys-LTs levels. Cys-LTs coefficient of variation (CV) was evaluated from different EBC in 5 healthy volunteers. Cys-LTs levels from EBCs in 13 healthy controls and 56 allergic rhinitic (n=31) and rhinitic/asthmatic (n=25) patients were also evaluated at baseline. Subsequently patients were randomized to receive either FP 100 microg/day per nostril or placebo for 2 weeks and then re-evaluated for EBC cys-LTs. The CV was 14.12%. EBC cys-LTs in allergic patients were significantly higher than in healthy subjects (70.9 vs. 20.6 pg/mL (median), P<0.05), while it did not differ between asthmatic/rhinitic and purely rhinitic patients. Treatment significantly reduced cys-LTs (from 93.6 to 19.9 pg/mL, P<0.001). This effect was evident both in asthmatic/rhinitic and in rhinitic patients. Treatment of AR with FP significantly reduces the levels of cys-LTs, major noninvasive markers of lower airway inflammation, suggesting that upper and lower airway inflammation is present and should be thus treated as a whole in subjects with AR with and without asthma.

Azelastine Nasal Spray and Fluticasone Nasal Spray in the Treatment of Geriatric Patients with Rhinitis

Treatment of Geriatric Patients with Rhinitis V. B. Behncke1, G. Alemar2, D. A. Kaufman1, F. J. Eidelman1; 1Allergy and Immunology, Cleveland Clinic Florida, Weston, FL, 2Otorhinolaryngology, Cleveland Clinic Florida, Weston, FL. RATIONALE: The prevalence and differential diagnosis of rhinitis changes over time, with nonallergic rhinitis increasingly prevalent in the fifth decade of life. This study was conducted to evaluate the effect of an antihistamine nasal spray (azelastine hydrochloride) and a corticosteroid nasal spray (fluticasone propionate) in treating geriatric patients with allergic or nonallergic rhinitis. METHODS: This was an open-label trial in 18 patients 65 years and older with a history of moderate-to-severe rhinitis. Eligible patients were randomized to treatment with either azelastine nasal spray 2 sprays per nostril bid (1.1 mg) or fluticasone 2 sprays per nostril qd (200 mcg) for a 6-week study period. The primary outcome variable was quality of life as assessed by the Rhinitis Quality of Life Questionnaire (RQLQ). Patients completed the RQLQ at baseline and at week 3 and week 6. Patients also recorded symptoms and side effects each day in a diary. RESULTS: Three patients had positive allergen skin tests and 15 had negative skin tests. Both treatments led to significant improvement from baseline in the RQLQ score after 3 and 6 weeks of treatment and there were no significant differences between treatment groups. Both treatments improved symptom scores compared to baseline, with statistically significant improvement at week 2 through 6 in the fluticasone group and at week 4 in the azelastine group. There were no significant differences between azelastine and fluticasone at week 6. CONCLUSIONS: Azelastine nasal spray and fluticasone nasal spray improved RQLQ scores and rhinitis symptom scores in geriatric patients with either allergic or nonallergic rhinitis.

Nasal fluticasone reduces exhaled bronchial cysteinyl leukotrienes in allergic patients

RATIONALE: Allergic rhinitis(AR) precedes and is often associated with bronchial asthma(BA). Indeed, local and systemic inflammation in these conditions are very similar. Cysteinyl leukotrienes(cys-LTs) are generated by inflammatory cells during late-phase allergic reactions and induce, in lower airways, smooth muscle contraction, microvascular leakage, and mucous hypersecretion. Cys-LTs are found in exhaled breath condensate(EBC) of asthmatics and irrespective of any bronchial symptom, are also found in EBC of rhinitic patients.