Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology
A 35-year-old CF is referred to the allergy clinic for symptoms of allergic rhinitis and conjunctivitis. She complains of itchy and watery eyes, itchy nose, nasal congestion, postnasal drip, itching in her ear and throat. These symptoms are seasonal and occur predominantly during the spring and summer. Triggers include exposure to grass. She has tried over-the-counter medications with good relief of symptoms but it does not last long enough. Immunotherapy has never been tried. No history of nasal polyps, eczema, food allergies, or systemic reactions to stinging insects.
Past medical history (PMH)
Exercise-induced asthma. She was on Azmacort and SABA (albuterol) PRN. A recent PFT and methacholine challenge test were reported as normal, and she was instructed to stop Azmacort and use albuterol prn for SOB on exertion.
Hives. She has intermittent episodes of single lesions that occur mostly over the arms and occasionally on the face. The lesions would disappear spontaneously within 24 hours. There are no identifiable triggers, specifically the hives are not related to ASA, NSAIDs or other medications, physical or temperate triggers. Episodes are mild that she does not feel an evaluation or medical therapy is needed.
Fluticasone (Flonase) 50 mcg/actuation nasal spray QHS, albuterol 90 PRN
No tobacco or alcohol use
Pets in the home: 2 dogs. Flooring: Wall-to-wall carpeting. Air conditioning: Central air. Heating: Forced hot air. Basement: Dry basement. Dust mite controls: Dust mite controls are not in place. Tobacco smoke: no exposure in the home.
Mother with asthma
HEENT: External ears normal. Canals clear. TM's normal. Nares normal. Septum midline. Congested pale mucosa, no polyps seen. No drainage or sinus tenderness. Lips, tongue normal. Oropharynx clear.
Neck: supple, no adenopathy
CVS: RRR, normal S1/S2, no m/r/g
Chest: CTA (B)
Extremities: no c/c/e
Skin: color, texture, turgor normal. No rashes or lesions.
What is the most likely diagnosis?
Allergic rhinitis and conjunctivitis.
What tests would you order?
Skin prick testing.
The allergen skin testing was positive as below:
What happened next?
The patient has allergic rhinitis with throat, eyes, and nasal symptoms during spring and summer seasons. She also has positive skin testing to grass, weeds, trees and mold.
Flonase was continued at a dose of 50 mcg nasal spray 1 squirt daily, she was advised to avoid septum when spraying. She was also instructed to increase Flonase to 2 squirts daily if symptoms worsen. Olopatadine (Patanol) 2 drops in both eyes bid was prescribed for control of her ocular symptoms. If symptoms are still not under control, she was advised to call the office for possibly adding an oral antihistamine.
Medication dosage, usage, side effects and goal of treatment were discussed. She was advised on the benefits of being indoors with air conditioning during spring, summer and fall.
Risks and benefits of immunotherapy for allergic rhinitis were discussed and the patient opted to start immunotherapy. A follow-up in 1 month was arranged.
Allergic rhinitis and conjunctivitis.
What did we learn from this case?
What nasal spray provides relief in 30 minutes in allergic rhinitis?
Patanase (olopatadine) is currently the only nasal spray to provide relief in 30 minutes in allergic rhinitis. The effect lasts for 12 hours.
Allergic rhinitis mind map.
Medications for Allergic Rhinitis
Treatment Options for Allergic Rhinitis (click to enlarge the image).
Ocular antihistamines (eye drops) (click to enlarge the image).
Rhinitis, Allergic. eMedicine, 2007.
Allergic Rhinitis. eMedicine, 2007.
Seasonal Allergic Rhinitis: A Short Review. V. Dimov, M.D., 2007.
FDA Approvals: Patanase, Actonel, Cimzia. Medscape, 2008.
Fluticasone furoate nasal spray is the only intranasal corticosteroid to reduce the ocular symptoms of seasonal allergic rhinitis consistently, JACI, 2010. http://goo.gl/oQ2n2