1  Sensitization to aeroallergens, animal dander, house dust mites and moulds among patients with allergic rhinitis in warm dry climates  Abbas H. Alsaeed  Assistant Professor and Consultant Hematologist  King Saud University, College of Medical Sciences  Dept. Of Clinical Laboratory Sciences

2 Variations in Defining Allergic Rhinitis  Allergic rhinitis was defined as the self-reported presence, in the previous year, of usual nasal blockage and discharge apart from colds or the flu, provoked by allergens, with or without conjunctivitis (Ng & Tan, 1994)  Rhinitis was defined as sneezing or a runny or blocked nose not due to a cold or the flu (Sly, 1999)  Individuals with rhinitis were defined as those suffering with three or more symptoms of rhinitis either throughout the year (perennial) or for part of the year (seasonal) (Frosh et al 1999)

3 Background  Pollutants have a direct effect on the nose by causing cellular damage and stimulating the release of inflammatory mediators (Bascom, 1991).  Prevalence rates of rhinitis symptoms among office workers reported in the western countries were around 30%, but could be as high as 60% in some offices (Finnegan 1984; Viegi et al 1991)

4 Symptoms of Allergic Rhinitis  * Sensitive to specific allergens, e.g. dust  * Pruritus of the nose, eyes palate, ears  * Sneezing more than two at a time  * Watery rhinorrhoea  * Coexistant asthma or eczema  * Seasonal symptomas  * Family history of allergies.

5 Classification Allergic Rhinitis  Seasonal Allergic Rhinitis (Hayfever) (SAR )  Perennial Allergic Rhinitis (PAR )  Occupational Allergens  Pollen from a variety of trees, grasses, and weeds.  HDM, Mold, Animal epithelial dander, Food (rare)  Chemicals

6 Perennial Allergic Rhinitis (PAR)  Patients with PAR are more likely than those with SAR to have asthma (Kubetin 2001).  Positive family history of allergic rhinitis.  Personal history of collateral allergy such as eczematous dermatitis, urticaria, and/or asthma.

7 Non-allergic Triggers  * Cold air  * Smoke and perfumes  * Strong odors  * Spicy/hot food  * Alcohol  * Pregnancy / hormones  * Decongestant nasal sprays * Medications, e.g. antihypertensive agents * Medications, e.g. antihypertensive agents (Druce 1998). (Druce 1998).

8 Symptoms of non-allergic rhinitis  * History of negative allergen specific IgE test  * Sensitive to temperature changes, smoke, perfume or environmental irritants  * Adult onset of symptoms  * Nasal crusting or drying.

9 Common Comorbidity  20-15% of allergic rhinitis patients had asthma  75-80% of asthma patients had allergic rhinitis  (Kirn 2001). SARPAR 23%50%Sinusitis 16%22%Asthma 14%14% Otitis Media

10 Objective 1- To investigate sensitization to aeroallergens, animal dander, HDM and mould in adult patients with allergic rhinitis in warm dry climates using an immunoblot assay. 2- To estimate the prevalence of rhinitis symptoms in warm climate. 3- To study the relationship between rhinitis symptoms and allergens.

11 Subjects  Thirty–eight adult patients (25 males and 13 females) with diagnosed allergic rhinitis  without a previous history of treatment attending the outpatient ENT clinic, from April 2002 to March 2005 on Alflah International Hospital, Saudi Arabia.

12Investigations  * History: present illness, past medical history, family history, environmental history, and impact on quality of life.  * Physical exam: nose, eyes, ears, lung, skin.  * Nasal exam with rhinoscope / flexible nasendoscope.  * Nasal smear for eosinophils.  * Nasal mucociliary clearance assessment: saccharin test, and ciliary best frequency measurement.  * Nasal airway assessment.  * Allergy tests: Allergen specific IgE

13 Allergy Test (Method) METHODTEST Blood serum is combined with allergen in trough allergen immunoblot assay (RIDA allergen screen) Blood Test Blood serum is combined with allergen in test tube. Radio-allergosorbent allergy testing (RAST) Direct exposure (e.g. via inhalation or ingestion to a likely allergen Provocation testing Percutaneous Prick testing Skin Test Percutaneous Scratch testing Intradermal injection Intradermal testing

14METHOD  Allergens are coated to the surface of nitrocellulose membranes lying in a reaction trough.  Patient serum pipetted into the reaction trough and incubated at RM, washing.  Allergy screen detection antibody were added and incubated again at RM, washing.  Streptavidin conjugate with alkaline phosphatase that binds to biotin in the test fields, and incubated at RM, washing.

15 Continue  Substrate a specific enzyme color reaction of alkaline phosphatase, and incubated at RM.  The reaction stopped by rinsing with water and analysis the results on the test strips (RIDA allergy screen 2002).  Negative control had not been coated with allergen, biotin-labelled bovine serum albumin had been applied as positive control.  The color intensity on the test fields is directly reflect to specific IgE antibody in the serum of the patients.

16 Figure ( ) Illustrates the results appearance on the surface of nitrocellulose membrane

17 Results  Specific IgE antibodies were detected in 65.8% of all the subjects.  Males demonstrated a higher rate than females (76% vs. 46.2%) or a M/F ratio of ~ 2:1.  The sensitization rate was highest for pollen while results for the other allergen groups are as follows :  pollen ( 68.3%), animal dander (23.9%),HDM (6.0%) and moulds (1.8%).  Among allergenic pollen mixed grasses were the most common cause of sensitization (11.1%) while alder, birch, rye and oak have the same, albeit lower sensitization rates ( 9.4%).  These plants are commonly cultivated for greening purposes in urban areas.

18 Continue results  Sensitization rate to cat and dog dander are (9.4% and 8.5% respectively), while dander from horse, guinea pig and golden hamster caused lower rates of sensitization (3.4% - 1.7%).  Dermatophagoides pteronyssinus and Dermatophagoides farinae are the most prevalent indoor sensitizers (4.3% and 1.7%, respectively).  Sensitization to mould is relatively rare ( 1.8%).

19 Table ( ) The relationship between absent and present of allergen specific IgE in rhinitis patients P value AllergenpresentAllergenabsentNo.Parameters < (65.8%) 13 (34.2%) 38Patients < (76.0%) 06 (24.0% 25Male (46.2%) 07 (53.8%) 13Female

20 Table ( ) Distribution of allergen antibodies in rhinitis patients Antibodies System % Allergen Ab. % Allergen Ab. No. AllergenSystem PollensAlderBirchHazel Mixed Gra. RyeMugwortPlantainOak

21 Continue Antibodies System % Allergen Ab. % Allergen Ab. No. AllergenSystem DandercatHorseDog Guinea pig Golden Ha. Rabbit

22 Continue HDM D. pterony. D. Farinae Mould A. Alternatae Pen. Notatum Cldsp. Hebar. Asp. Fumiga Total

23 Table ( ) Patients with one or multiple allergen antibodies developed. Sensitized Pt. (%) (%) No. of Patients (%) (%) No. of Allergen Ab. developed 24 % 04 % 12 % 08 % 12 % 04 % 16 % 04 % 06 (15.8%) 01 (2.6%) 03 (7.9%) 02 (5.3%) 03 (7.9%) 01 (2.6%) 04 (10.5%) 01 (2.6%) Total

24

25 Report of Prevalence Rates in Allergic Rhinitis (variation in methodology) YearCountryAgePrevalence 1991UK % 1994Turkey High school 62.5% 1996Turkey 51.0% 1994Singapore % 1994Singapore % 2000Denmark % 2002Italy % 2002Bangkok U student 26.3%

26 Prevalence of Rhinitis in UK YearAuthorAgePrevalence 1998 Lau et al % 1997 Leung et al % % 2001 Tong et al. Workers49.5%

27 Discussion

28

29 Conclusions  The results of this study show that even in warm climates pollen, animal dander and HDM allergens may be important sensitizing allergens. Pollens of local horticultural plants are the main sensitizing allergens among patients with allergic rhinitis in the locality studied.   The practice of greening the country seems to contribute to increased rates of allergic sensitization of persons prone to allergic rhinitis. Local environmental and genetic factors are probably involved in the pathogenesis of the disease.

30 Treatment * Identification of the responsible allergens * Health education on allergen avoidance Allergen avoidance * Antihistamines. * Topical corticosteroids. * Anticholinergics. * Decongestants Immunotherapy-injection Sublingual Sublingual Medical treatment

31 Treatment Symptomatic treatments Symptoms * Azelastine HCL nasal spray * Oral decongestant Nasal obstruction due to nonallergic rhinitis * Increase water intake. * Nasal saline irrigation. * Humidity to bedroom. Non-purulent chronic post nasal drip * Intranasal cortisteroid. * Atrovent spray. * Nasal saline Bilateral anterior rhinorrhea