Dr ARIF AHMED M.D.(Paed.), D.Ch., M.D.(USA), European Board (EACCI) Certified in Allergy & Immunology
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1 Case Based Approach to Allergic Unified Airway Diseases Dr ARIF AHMED M.D.(Paed.), D.Ch., M.D.(USA), European Board (EACCI) Certified in Allergy & Immunology
2 Recent Advances in Pediatrics 23: Hot Topics The Child with Allergy M Arif Ahmed
3 Unified Airway
4 Definitions
5 Natural History of Allergic Diseases in Atopic Children
6 Important Cells in Allergy
7 The Early Phase Response (within minutes)
8 The Late Phase Response (Occurs 2-8 hrs post allergen challenge)
9 Allergic Cascade (Summary)
10 Risk Factors for Allergic Rhinitis
11 CASE 1 Zaid 2 1/2 year male NRI from Australia brought to a clinic for the complaint of a constant cold. It was also noticed that the child was not interacting well. On examination no significant finding What further would you do?
12 Case I(Contd.) Child was suspected to have autism by his GP. Speech delayed (3-4 words) Snoring present. No other associated symptoms Not much active with peers and very restless at all times What is your diagnosis and what tests would you do Otoscope-attempted but movement of ear drum not appreciated Tympanometry -Bilateral middle ear effusion X-ray NP- moderate enlargement of adenoids
13 Case I(Contd.) Bilateral Middle ear effussion with adenoidal enlargement Now what would be your diagnosis and how would you treat 2 week course of intra nasal mometasone + monteleukast + antibiotic+/-
14 Repeat Tympanometry showed no effusion. Child was more interactive and the restlessness had come down What further tests are required Immunocap method results were 1.D.Farinae :68.70(very highly symptom relation) (N<0.01) 2.D-pteronyssinus :52.70 (very highly symptom relation) Hearing test Environmental aeroallergens Control Mometasone or Mometasone + Monteleukast or Monteleukast Only ENT opinion T-Adenoidectomy. The possibility of autistic spectrum
15 What is Allergic Rhinitis? A major Chronic Respiratory Disease!
16 Allergic Rhinitis Not a Trivial Disease!
17 Arif Ahmed, Comparative Review of Allergic Rhinitis between the USA and India, IJCMR, June 2016
18 Clinical Presentation of Allergic Rhinitis 4 Major Symptoms Sneezing Itching Rhinorrhea Congestion Nasal Block or Obstruction 2 or more of symptoms > than 1 hr for most of days is Allergic Rhinitis
19 Diagnosis of Allergic Rhinitis Clinical! Clinical! Clinical! Clinical!
20 CASE II Sonali 5 year f/ch- H/o repeated wheezing Each episode-cold (nasal itching +runny nose) +/- low grade fever. Relieved - course of antibiotics+ monteluekast+anti histamine + nebulisation
21 Differential Diagnosis Common Cold vs. Allergic Rhinitis
22 What would be the further line of approach? Cough-at times of episodes on lying down at night Family History & Drug Allergy-Nil Father Smokes but not in presence of the family Snoring and mouth breathing. Examination is Normal. X-Ray- adenoids What is your diagnosis and how would you approach
23 80.00% 73.68% 70.00% 64.86% 60.00% 57.50% 50.00% 40.00% 42.50% 35.14% Positive Negative 30.00% 26.31% Positive Negative Total 20.00% 10.00% 0.00% Grade 1 Grade 2 Grade 3 Response percentage of adenoid hypertrophy grades to dust mite allergen extracts in SPT Association of HDM with AH increases with grade(p=0.03) Ahmed M A, Evaluation of Dust Mite Allergy in Children with Adenoid hypertrophy, Annals of Allergy Nov 16 Grade % Grade % Grade % Total % % % % % % % % % Chi square = df=2 P value= 0.038
24 Case II(Contd.) What is your diagnosis and how would you approach Patient has only one question- Is this ASTHMA or WILL IT GO AWAY
25 Ruling out Atopy Clinical Role of Skin Testing/ Immunocap Skin prick test Normal
26 Management Role of Monteleukast Role of antihistamines Role of Salbutamol(inhaled/Oral) Role of Salmeterol+ Fluticasone/ Budesonide Prophylaxis Role of Antibiotics
27 CASE III Jabeen 14 year F/ch - episodes of repeated blocked nose and runny nose since age of 6 years. What further history No nasal itch and sneezing Repeated eye discharge and itching. No episodes of wheezing and no skin changes. Repeated episodes of headache, sleeps at day time and thus missed schools. Family history of similar complaints-nil Examination: average built chest normal. Ears wax. Nasal bilateral congestion Sinuses Mild tenderness in maxillary area Eyes -normal What is the diagnosis?
28 Clinical Classification (ARIA)Categorization of Duration & Severity
29 Case III(Contd.) ARS Moderate severe Persistent How do you manage this child at this stage? 1. Antihistamines 2. Intranasal steroids alone 3. INS+ Montelukast
30
31 Triggers for Allergic Rhinitis
32 Dust Mites as Triggers of Allergic Rhinitis
33 Pollens as Triggers of Allergic Rhinitis
34 Fungus as Triggers of Allergic Rhinitis
35 Pets as Triggers of Allergic Rhinitis
36 Cockroaches as Triggers of Allergic Rhinitis
37 Case III(Contd.) She has had treatment with combination of montelukast+ levocetrizine + fluticasone OD on a daily basis since 9 months and now her quality of life is better. She is able to attend school daily. What would be your further line of approach?
38 Case III(Contd.) Spirometry : mild bronchial hyperresponsiveness Mites 1.D.Farinae : 6 mm 2.D-pteronyssinus : 7 mm 3.Blomia sp : 5 mm Fungi Cladosporium herbarum :4 mm
39 How Skin Prick Test High Sensitivity Greater Selection of Antigen Available in minutes Less Expensive Minimal Equipment Allergy Blood Test Medications no affect on results Not depend on skin condition Truly quantitative, allows monitoring after intervention
40 Reagents
41 Commonly used prick method Demonstrate allergen sige Correlate well with clinical history and challenge test Simple, safe & inexpensive More specific and sensitive Avoid H1 antihistamines before test Prerequisite for starting Immunotherapy
42 Prick to Prick Test
43 CLINICAL RELEVANCE DIAGNOSIS OF ALLERGIC RHINITIS OR ASTHMA Treatment options Allergen Avoidance Choice of Pharmacotherapy Immunotherapy SPECIAL RELEVANCE IN CHILDREN Skin prick test positive Wheeze and cough without fever Progressive symptoms Likely to be a persistent wheezer
44 CLINICAL RELEVANCE (cont.) ALLERGY THRESHOLD Amount of allergen particles required to initiate an allergic response Varies from patient to patient and within the same patient with time Explains the variation in clinical symptoms
45 PITFALLS Inhalants Are all the antigens that the patient is sensitized to clinically relevant? Only those antigens that correlate clinically Many patients are sensitized to antigens- do not react with clinical expressionl Normal subjects also show sensitization (Mahesh P A et ahdm 28%) A good history and knowledge of local aerobiology - critical in judging clinical relevance.
46 Case IV Yash 14 yr. M/ch-Constant sneezing especially at night time X 1 month There is a blocked nose. Sleep and daily activity totally disturbed
47 Case 1 (Contd.) Started on monteleukast +anti histamine+ mometasone Improved only after the 14 th day of treatment Also started on alternative medicine on 10 th day Since than better and is on allopathic medicine H/o constant headache 2 years back X 1 year. Treated as migraine by neurologist. Since mum also has migraine Review of CT scan done 2 years back - maxillary sinusitis+ nasal polyp
48 Case 1(Contd.) What is the diagnosis Could the diagnosis of migraine made earlier be wrong How do you explain the improvement on 14 th day What test would you do -Skin Prick Test-SPT Positive for all 3 types of dust mites
49 Initiating Immunotherapy IgE-mediated disease -+ve SPT and/or serum specific IgE Documentation- clinical sensitivity Characterization of other triggers involved in symptoms Severity & duration of symptoms- Subjective symptoms Objective parameters(work loss, school absenteeism PFT (essential): exclude patients with severe asthma Response to allergen avoidance & pharmacotherapy Contraindications -P-blocker,immune disease,compliance Sociologic factors, cost,occupation of candidate Impaired QOL despite adequate pharmacologic treatment Availability of standardized or high-quality vaccines
50 SCIT Only approved route of administration in USA weekly/biweekly SC extract of allergen, in solution, in increasing doses until standard maintenance dose is reached Maintenance:sc regularly (intervals of approx. 20 days) not less than 3 years SLIT SLIT used & investigated since late 1980 s in Europe Keep the extract under the tongue for a couple of minutes and then swallow it
51 Subcutaneous and Sublingual Immunotherapy Nelson HS. J Allergy Clin Immunol Pract 2014;2:144-9
52 Take Home Messages Concept of a Unified Airway to be considered in diagnosis Allergy affection of the Unified Airway is very common. Manifestations are protean and varied and need to borne at the back of the mind Necessary to find Allergen with good history, SPT or Immunocap. Environmental Control is essential Choose the right combinations and teach the right technique
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