Allergic Rhinitis Pathophys

Describe what occurs with the non atopy response

- Allergens produce IgG1 and 4 antibodies - it is a much lower response, results in moderate activation of Thelper 1 cells - less activating IL's produced through this process

What does non atopy allergic rhinitis involve?

- Allergens produce specific IgG antibodies - Moderate T cell response

What is IgE?

- Antibody that is responsible for hypersensitivity reactions - It is bound to mast cells and B cells - Responsible for early and late phase reactions

What occurs during the immediate phase reaction?

- Antigen binds with IgE located on your mast cell. This causes histamine release which is the primary mediatory

What medications must be stopped before an allergy test?

- Antihistamines- first and second generation - TCA's - H2 antagonists - Phneothiazines

What questions would you ask a patient who thinks they have allergic rhinitis?

- How long has it been going on? - Do you have a fever - How often does it occur - When does it occur- year long or seasonally? - How often do symptoms occur - What medications are you on? - Family history- genetic predisposition - Do you have environmental triggers

What are differential diagnosis for allergies?

- Infectious Rhinitis - NARES (Nonallergenic rhinitis with eosinophilia syndrome) - Food or alcohol induced allergic rhinitis - Drug induced rhinitis - Nasal polyps- little seeds of polyps that cause obstruction - Hormone rhinitis - Occupational rhinitis

What is the antigen- antibody response?

- Patients with allergies have an excess of basophils and mast cells in the nose - Each cell contains mast cell contains IgE

What are allergy testings?

- done in the MD office. You are given a diluted allergen that is inserted intradermally or percutaneous - There are Positive and negative control compared - You will see a wheel and flare reaction - you must stop medications in advance that block histamine

What causes atopy?

- exaggerated response to allergies - T helper 2 cells produce highly activating IL 3,4,5

What are risk factors for allergic rhinitis?

- family history of atopy, atopic dermatitis, asthma - IgE > 100 IU/ mL before the age of 6 - higher socioeconomic class - presence of a positive allergy skin prick test

What is the nasal functions on air particles?

1. Heats air 2. Humidifies air 3. Cleans the air *** The folds have cilia that push allergens and mucous down the throat- takes to your stomach where you can digest it.

What is the second phase rapid response?

1. Increased inflammation- t cells 2. Augments antibody response- t cells 3. Cytotoxic response- t cell 4. Secretion of antibodies- b cell 5. production memory b cell- b cell

Review of cell mediated immunity

1. Non specific at first 2. Involves neutrophils, cytokines, and NK cells that attack foreign pathogens 3. T cells form in the thymus antigen specific CD4 or CD8 cells 4. Cytotoxic or antibody response

how do lymphocytes play a role in allergic rhinitis?

1. Produce antigen-specific IgE, which makes hosts sensitive to the allergen 2. Re-exposure causes a release of high amounts of inflammatory mediators. Inflammatory mediators include: histamine, platelet activating factor, and leukotrienes

What are the categories of allergic rhinitis?

1. Seasonal vs perennial 2. Mild or moderate- severe 3. Persistant or intermittent

Review of humoral immunity

1. T cell dependent pathway- increase antibody production, memory B cells are produced resulting in long lasting and rapid immune response 2. T cell independent pathway- Increase antibody production, short lived response, poor specificity

When does the late phase reaction occur?

4-8 hours after the initial exposure

What is a confirmatory wheal measurement?

9 mm

What are environmental factors that cause allergic rhinitis

Allergen sensitization Having few siblings Excessinve hygiene Receiving antibiotics in the first 2 years of life Vaccination and prevention of disease

What are common diseases associated with atopy?

Allergic rhinitis Asthma Atopic eczema

What is allergic rhinitis?

An IgE mediated process resulting in inflammation of muscosal membrane. Need to know the playmaker is IgE!

Example of perennial allergies

Animal allergens Dust mites mold

What is moderate- severe allergic rhinitis?

At least one of the following: Sleep disturbance Impairment of daily activities Impairment of school or work Troublesome Symptoms

What defects in target organs can cause allergic rhinitis?

Bronchial epithelium Skin Gut

What objective information is consistent with allergic rhinitis?

Clear rhinorrhea Tearing conjunctiva Allergic shiners

What is adaptive immunity?

Delayed response with our cellular T cells and humoral B cells

What are complications of allergic rhinitis?

Disturbed sleep Malaise, fatigue Poor work or school performance Decreased smell and taste Sinusitis Nasal polyps Cough, hoarseness Otitis media- children Mouth breathing--> dental problems Asthma Epistaxis

When you diagnose allergies what PMH do you need?

Duration of symptoms- intermittent, persistant? Time when symptoms occur Response to medications Coexisting conditions Current living environment Precipitating factors Family history Surgical history

What occurs (pathophys) of the late phase reactions?

Exposed to an allergen, there is a response given by T helper 2 cells and IL 3,4 5 are produced. This causes eosinophil aggregation which is what causes nasal obstruction and congestion

What are other symptoms of allergic rhinitis?

Fatigue Poor work or school performance Loss of smell or taste Hoarseness Mouth breathing Epistaxis

What is atopy?

Hereditary predisposition to produce IgE antibodies against environmental allergens. Allergic rhinitis can be hereditary

Seasonal and perennial allergies are due to _____ mediated reactions

IgE

What is innate immunity?

Immediate response to something.

What is the key player with the immediate phase reaction?

Mast cells

What are nasal scrapings?

Microscopic review of nasal smear Positive if eosinophils are present Low specificity

Rhinitis is characterized by 1 or more of the following symptoms __________ (4)

Nasal congestion rhinorrhea sneezing itching

What are tests you can do for diagnosis of allergies?

Nasal scrapings allergy testing

What is our second line innate immune response?

Neutrophils Cytokines Monocytes Acute phase proteins

What is mild allergic rhinitis

No impact on quality of life

________ is a low grade response to allergens

Non atopy response

Example of seasonal allergies

POllen

______ allergies occur throughout the year. May be sensitive to multiple different alllergens

Perennial

What is our first line innate immune response?

Physical barriers- skin Chemical barriers- stomach acid Microbial barriers

What things are you looking for during a PE?

Positive signs Transverse nasal crease "Shiners" Eye Folds Nasal Salute Pale bluish, edematous, nasal turbinates Thin clear rhinorrhea Tearing conjunctiva Periorbital swelling

______ allergies- symptom length and duration is based on climate and geography, they occur during specific times of the year when aeroallergen is present.

Seasonal

What are signs of allergic rhinitis?

Shiners Eye folds Transverse nasal crease Clear rhinorrhea Pruritic eyes, ears, and nose

What are symptoms of allergic rhinitis?

Sneezing Nasal congestion Postnasal drip Commonly associated with allergic conjunctivitis

What is associated with the immediate phase reaction?

Sneezing itching rhinorrhea obstruction

What is persistent allergic rhinitis?

Symptoms are present at least 4 days a week and for at least 4 weeks.

What is intermittent allergic rhinitis?

Symptoms are present for less than 4 days a week or for less than 4 weeks

Sally is a 38 year old female who visits your pharmacy today complaining of a runny nose and itchy eyes. Furthermore, she can't sleep at night, which causes her difficulty concentrating at work. The symptoms started 2 days ago and have progressively worsened. She claims that she has really bad colds every fall that last a month, but does not know what to do besides taking vitamin c and zinc supplements. Physical exam: Allergic shiners, tearing conjunctiva, and clear rhinorrhea. What subjective information is consistent with allergic rhinitis?

Timing of symptoms- every fall Triggers- unknown Frequency- intermittent Symptoms- runny nose, itchy eyes, fatigue Impact on work

T or F- people in a clean environment with less exposure to allergens and bacteria are more likely to have allergic rhinitis

True

What are triggers of allergic rhinitis?

Viral infections Exposure to allergens Tobacco smoke Indoor and outdoor pollutants

What happens when we have memory B cells?

You have a fast response when exposed to the disease or allergen. You have a second phase rapid response. You are uploading antigens to allergens

____ is the second leading cause of chronic disease in the US. This is a chronic disease, cold is self limiting

allergic rhinitis

The late phase reaction is ______ driven

cytokine- this is responsible for the persistent symptoms of allergic rhinitis

The late phase occurs within ________ . _______ produce _______ (key player) causing congestion, obstruction, and mucosal inflammation

hours T helper 2 cells IL 3,4,5

The early phase reaction occurs in _______ due to _______ which produce _______ (key player) you get rhinorrhea, itching, watery eyes, and sneezing

minutes mast cells histamine

What is the late phase reaction associated with?

nasal obstruction and congestion

When does the immediate phase reaction occur?

within 4-8 minutes