alergi.ppt
Transcript of alergi.ppt
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• The most prevalent of type I allergic dis.
• The symptoms and signs caused by
mediators :
vessels, glands and nerves.
• Classified as inflammatory disease.
ALLERGIC RHINITIS :
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ALLERGIC RHINITIS :
• Sign & symptoms :– Itching nose– Sneezing– Rhinorrhea– Nasal obstruction
Allergic salute
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EPIDEMIOLOGY• Prevalence in ISAAC (Asher 1995) :
0.8 – 14.95 % in 6-7 years old 1.4 – 39.7 % in 13 – 14 years old
• Low pervalence : Indonesia, Georgia, Greece • Semarang (2002) ISAAC phase 3, RA : 18,6% • High pervalence : Australia, UK and Latin America• In adults : no equivalent to ISAAC study • National survey : 5.9 % France and 29 % UK
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WHO Classification of Allergic rhinitis
1. INTERMITTENT – Less than 4 days a week, or– Less than 4 weeks
2. PERSISTENT– More than 4 days a week, and– More than 4 weeks
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SEVERITY OF THE DISEASE
1. MILD – means no one of the following items are present– Sleep disturbance– Impairment of daily activities / sport– Impairment of school / work– Troublesome symptoms
2. MODERATE – SEVERE, when one or more of the symptoms are present
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( Adapted from Creticos, 1998 )
-
MHC
Fragment
Th2
PATOFISIOLOGI
CHRONIC
INFLAMMATION
(LATE PHASE)
RhinoreaSneezing
Congestion
ACUT
E
SYMTOMS
Rhinorea
Sneezing
Congestion
Basic proteins
LtsCytokines
HISTAMINELts
Cytokines
HistamineTriptasePGD2LTsCytokines
E A R L Y P H A S E
IgE-bearing B-cellsIgE-bearing B-cells
IgE antibody IgE antibody IgE IgE
IgE IgE
Mastosit
3
LATE P H A S E
(I)
(II)
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MECHANISMS OF Allergic RHINITIS
Mast cell
HistamineLeukotrienesProstaglandin'sBradykinin,PAF
Itch, sneezingWatery dischargeNasal congestion
allergen
Th2 cell
B cell
eosinophils Nasal blockadeLoss of smellNasal hyperreactivity
IL4
IgE
IL 3, 5, GMCSF
Immediate rhinitis symptoms
Chronic ongoing rhinitis
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MAST CELL DEGRANULATION
Histamine, Heparin, Tryptase, TNF , TGF , IL 3, 4, 5, 13
Newly formed mediators
PLA2 AA + PAF
C.O 5 L.O
PGD2 LTC4 LTB
LTD4
LTE4
Y
Yallergen
Preformed mediators
Y Y
Y
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HISTAMINE
HH11-R-R
DEGRADATION( histamine methyl transferase)
CNS Endothelium(Vascular Permeability)
Nociceptive Nerves
• Itch.• Systemic Reflexes Sneeze Allergic Salute
Serous/Mucous Secretion• Parasympathic Reflexes Glandular Exocytosis
HISTAMINE EFFECTS
Vascular wall
Vasodilatation
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Diagram of DIAGNOSTIC PROCEDURES (1)
patients with AR symptoms ( history of illness + physical exam.)
skin prick test
(+)
AR with complications / concomitant dis
AR without complication
eosinophil on nasal cytology
(+)
allergic Rhinitis ?
(-)
non allergic rhinitis
NARES
(-)
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Diagnostic Procedures (2)
1. Anamnesis– Chief complain :
1. Itching nose
2. Sneezing : morning >>
3. Serous nasal secretion
4. Nasal obstruction at night
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Diagnostic Procedures (3)
1. Anamnesis
– The symptoms was environment related
– History of other allergic manifestation of patients and other allergic familial manifestations
– Duration of illness, severity of the disease and the respond of the previous treatment
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Diagnostic Procedures
2. Physical examination Should be performed with appropriate lighting
and use of nasal speculum
normal oedema
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Diagnostic Procedures (5)2. Physical examination
– Including : 1. Nasal passage ways
2. Nasal mucosa
3. Turbinates
4. Secretion
5. Septum
6. Polyps ?
7. Sinusitis ?
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Diagnostic Procedures (6)
3. Nasal cytology
– Large number of eosinophils may aid to differentiate AR & NARES from other Rhinitis
– No consensus to routinely performed for evaluation of rhinitis
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Diagnostic Procedures (7)
4. Total serum Ig E
– Neither very sensitive nor very specific
– 35 – 50 % AR Normal Ig E levels
– Poor correlation with symptom and skin testing result
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Diagnostic Procedures (8)
5. Nasal provocation testing
– Based on a history of AR symptoms provoked by allergen exposure and confirmed by skin testing
– It may be required for confirmation of sensitivity to allergen in the work place
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Diagnostic Procedures (9)
6. Special diagnostic techniques
– Upper airway endoscopy / Rhinomanometry
– Standard radiographs
– CT
– MRI
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Diagnostic Procedures (10)7. Testing for specific Ig E,
important for :
– Determining whether patient has allergic rhinitis
– Identifying specific allergen for avoidance measurement and allergen immunotherapy
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Diagnostic Procedures (11)
8. Skin testing to allergen : – Simple– Ease– Rapid performance– Low cost– High sensitivity / spesificity ( Prick test )
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Allergy skin prick testing
Skin prick test :
positive result
wheal > 3mm diameter
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A R and other diseases
Allergic Rhinitis
O M E
Nasal polyp
Sinusitis
U R T infection
Bronkhial
asthma
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Comorbidity AR and Sinusitis
• US : sinusitis 30 Mill / year (1989 ) sinusitis : 25 – 30 % AR
non sinusitis : 14 – 17 % AR
• Sinusitis ( dx CT ) Newman at all 1994 :– AR : 78 %
– Asthma : 71 %
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Differential diagnosis of RA
Non – allergic rhinitis :• Infectious : bacterial, viral, fungal
• Drug induced : aspirin & other medications
• Occupational rhinitis (allergy & non allergy)
• Hormonal : puberty, pregnancy, menstruation
and hormonal disorders
• Other causes : foods, irritants, emotions,
NARES
• Atrophic Rhinitis
• Idiopatic
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Management of AR
Objectives :
– relieving symptoms for improving QOL
– to avoid triggering factor
– to avoid / to treat complication
– to change the natural history
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Allergen elimination
EDUCATION
– Explain what is allergic rhinitis / reaction
– Explain the meaning of pos. allergic skin test
– Confirm whether there is correlation between allergen contact & rhinitis attack
– Explain how to do allergen avoidance
– Encourage to avoid the allergens
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Globally important allergens
mites
pollen
mites sources
weed cockroaches
pets : dogs
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• Pharmacological treatment
1. ANTIHISTAMINE– First line– Consider new antihistamine since :• Long acting more practical• No sedating normal daily activity• No / less cardiac effect• Broad spectrum effects
– Except :• Patient doesn’t mind sedation effect• It is not available• Can not be afforded Classic antihistamine can be considered
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2. NASAL DECONGESTANT• Indicated in patient with prominent nasal
obstruction complaint• As addition / combination with A H
Long term treatment– Systemic nasal decongestant, be careful
in hypertension cases and glaucoma.– Topical : rebound effect
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3. INTRANASAL CORTICOSTEROID
– Long term treatment safer than systemic application
– Effective to control AR symptoms Note :– Patients should be well informed how to
use – Symptoms relieve is not directly achieved – In some places it is unavailable
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• Allergen Specific Immunotherapy ( ASIT )
ASIT : effective for treating allergic rhinitis
Recommended in patients with :
– severe symptoms
– failed by pharmacological treatment
– positive correlation skin test & history
– agree & well informed about duration, schedule of injection & expected results
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Updated ARIA recommendation
(Allergy Supl 86: 63 2008)
Intermittent symptoms Persistent symptoms
MildNot in preferred
orderOral H1 blocker
or intranasaland/or
decongestant
Moderate-severe Mild
Not in preferred orderOral/ intranasal H1 blocker
And/ or decongestantor intranasal CS
In persistent ARReview after 2-4 weeks
If failure, step upIf improved: continue for
1 mo
Moderate- severe
In preferred orderIntra nasal CS, H1 blocker
Review after 2-4 weeks
improved failure
Step-down& continue >
1mo Review : Dx, complianceInfection or other causes
Increase intranasal CS
doses
Rhhinorrheaadd ipratropium
Blockade, add decongestant or
Oral CS
Failure: referred
Consider specific immunotherapy
Diagnosis of Allergic rhinitis Check for asthma
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Intermittent AR : Adults & children
Is therapy needed ? If yes
Non-pharmacological therapyAllergen avoidance measure
Is pharmacotherapy needed ? If yes
Mild disease Moderate disease Severe disease
Oral/nasal AH or cromon
Nasal corticosteroids
Nasal CS & oral/ nasal AH
Add further symptomatic treatment
OrShort course oral CS
Or Consider IT
If inadequatecontrol
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Persistent AR : Adults Is therapy needed ? If yes
Non-pharmacological therapyAllergen avoidance measure
Environment control
Is pharmacotherapy needed ? If yes
Mild disease Moderate disease Severe disease
Oral/ nasal antihistamine
Nasal corticosteroids
Nasal CS & Oral antihistamine
If inadequatecontrol If resistent
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If resistent
Nasal blockage
RhinorrheaAntihistamine and
Oral / nasal decongestant
OrShort course oral
steroid
Nasal ipratropium bromide
If persistent
ConsiderImmunotherapy
If inadequate control
Further examination & consider immunotherapy
Or Surgical turbinate reduction