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Cases
Asthma Plus?
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Background
A 32-year-old man presents to the hospital with worsening of his asthma symptoms. He has a life-long history of mild asthma that is controlled with low-dose inhaled budesonide. Over the past 2 years, escalation of the budesonide dose, frequent use of salbutamol, and occasional use of short-course prednisone have been required to maintain asthma control. He is a nonsmoker and takes no other medications. His environment and work are unchanged, and he is otherwise healthy. Physical examination reveals boggy, pale nasal mucosa and minimal watery secretions. A few expiratory wheezes are audible on auscultation. The patient's forced expiratory volume in 1 second (FEV1) is 75% predicted, and his FEV1/forced expiratory capacity (FVC) ratio is 65%. What is the cause of his uncontrolled asthma?.
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down for Hint and Answer
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***** HINT *****
He has the "allergic salute."
***** ANSWER *****
Allergic rhinitis: Patients with asthma should be evaluated for allergic rhinitis, a common asthma trigger. Early diagnosis and treatment of allergic rhinitis are crucial in those with uncontrolled asthma. Allergic rhinitis, a common chronic illness, affects patients' quality of life and has astounding direct and indirect medical costs. The allergic inflammatory response results in the release of various chemical mediators that produce the clinical manifestations. The symptoms of allergic rhinitis include nasal congestion, itchy nose, sneezing, rhinorrhea, watery eyes, chronic cough, dry throat, and facial pain from sinusitis. Findings on examination are boggy, pale or bluish nasal mucosa and watery discharge. Repeated rubbing of the nose causes a dorsal nasal crease (ie, allergic salute), which is shown on the image above (arrow). Allergic rhinitis is usually diagnosed on the basis of clinical features, but it may be confirmed by means of allergy tests or in vitro blood tests.
Treatment with intranasal corticosteroids (eg, Nasacort, Flonase, Rhinocort, Nasonex) is the most effective therapy for allergic rhinitis. These drugs are recommended for all stages of allergic rhinitis, including moderate-to-severe persistent rhinitis, for which these medications are considered the most appropriate therapy. Nasal corticosteroids effectively treat most allergic rhinitis symptoms, including sneezing, rhinorrhea, itching, and nasal congestion.
Published studies have shown that nasal steroids are superior to nonsedating histamines, leukotriene receptor antagonists, and the combination of the two. All brands of nasal steroids are equally effective and safe; major differences are related to their taste, smell, ease of use, technique of application, and spray volume. These attributes, along with the patient's preferences, determine compliance and long-term outcomes. A recent placebo-controlled study demonstrated no significant difference in efficacy between budesonide and fluticasone; however, patients treated with budesonide had greater improvement in quality of life. Therefore, treatment with nasal steroids is the most effective therapy for allergic rhinitis and plays an important role in the management of comorbidities such as asthma, rhinitis, and nasal polyposis.
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References
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Bousquet J, Van Cauwenberge P, Khaltaev N; Aria Workshop Group; World Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108(5 suppl):S147-S334.
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Ciprandi G, Canonica WG, Grosclaude M, et al. Effects of budesonide and fluticasone propionate in a placebo-controlled study on symptoms and quality of life in seasonal allergic rhinitis. Allergy. 2002;57:586-591. Abstract.
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Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol. 1998;81(5Pt2):478-518.
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Kaliner MA. Patient preferences and satisfaction with prescribed nasal steroids for allergic rhinitis. Allergy Astma Proc. 2001;22(6 suppl):S11-S15.
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Yanez A, Rodrigo GJ. Intranasal corticosteroids versus topical H1 receptor antagonists for the treatment of allergic rhinitis: a systemic review with meta-analysis. Ann Allergy Asthma Immunol. 2002;89:479-484. Abstract.
Author:
Sat Sharma, MD
Associate Professor, University of Manitoba, Division of Pulmonary Medicine
eMedicine Editor:
Nicholas Lorenzo, MD
Chief Publishing Officer, eMedicine
Source
http://emedicine.com
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