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Aspirin-exacerbated respiratory disease (AERD) is characterized by the clinical triad of chronic rhinosinusitis with nasal polyps, asthma, and an intolerance to medications that inhibit the cycloxgenase-1 enzyme. Patients with AERD on average have more severe respiratory disease compared with patients with chronic rhinosinusitis with nasal polyps and/or asthma alone. Although patients with AERD traditionally develop significant upper and lower respiratory tract symptoms on ingestion of cycloxgenase-1 inhibitors, most of these same patients report clinical benefit when desensitized to aspirin and maintained on daily aspirin therapy. This Work Group Report provides a comprehensive review of aspirin challenges, aspirin desensitizations, and maintenance aspirin therapy in patients with AERD. Identification of appropriate candidates, indications and contraindications, medical and surgical optimization strategies, protocols, medical management during the desensitization, and recommendations for maintenance aspirin therapy following desensitization are reviewed. Also included is a summary of studies evaluating the clinical efficacy of aspirin therapy after desensitization as well as a discussion on the possible cellular and molecular mechanisms explaining how this therapy provides unique benefit to patients with AERD. [ABSTRACT FROM AUTHOR]

Local allergic rhinitis (LAR) is a differentiated rhinitis phenotype defined by perennial or seasonal rhinitis symptoms without systemic atopy. The diagnosis can be made by a positive response to the nasal allergen challenge (NAC) (the gold standard for diagnosis) in the absence of skin prick test and/or serum allergenspecific immunoglobulin E. Clinical and epidemiological studies have demonstrated that LAR affects individuals from different countries, races, and age ranges. Several studies have shown that the onset of nasal symptoms occurs during childhood in a significant proportion of LAR individuals. Evidence of LAR has been growing, especially in pediatric and Asian populations. A review of the literature reveals that most LAR studies of pediatric populations have appeared in the last three years. The prevalence of LAR in children ranges from 3.7% to 66.6%, and similar to what has been observed in adults, prevalence is higher in Western countries. Publications have shown that LAR in children can be either seasonal or perennial, and diagnosis of LAR confirmed by NAC have been reported with numerous allergens (house dust mites, pollens, molds, and dander). These findings illustrate that LAR is an important differential diagnosis in children with presumed non-allergic rhinitis, and a through review of the very recent literature can contribute to the clinical identification and diagnosis of LAR in children with no evidence of systemic atopy, as well as update readers' knowledge of the topic. [ABSTRACT FROM AUTHOR]

Nasal allergen challenge (NAC) is applied in a variety of settings (research centers, specialty clinics, and hospitals) as a useful diagnostic and research tool. NAC is indicated for diagnosis of seasonal and perennial allergic rhinitis, local allergic rhinitis, and occupational rhinitis; to design the composition of allergen immunotherapy in patients who are polysensitized; and to investigate the physio-pathological mechanisms of nasal diseases. NAC is currently a safe and reproducible technique, although it is time- and resource-consuming. NAC can be performed by a variety of methods, but the lack of a uniform technique for performing and recording the outcomes represents a challenge for those considering NAC as a clinical tool in the office. The availability of standardized allergens for NAC is also different in each country. The objective of this workgroup report is to review the current information about NAC, focusing on the practical aspects and application for diagnosis of difficult rhinitis phenotypes (eg, local allergic rhinitis, occupational rhinitis), taking into account the particular context of practice in the United States and the European Union. [ABSTRACT FROM AUTHOR]

Background: Local allergic rhinitis (LAR) is a common disease that affects 25.7% of the rhinitis population and more than 47% of patients previously diagnosed with nonallergic rhinitis. Whether LAR is the first step in the natural history of allergic rhinitis (AR) with systemic atopy or a consistent entity is unknown. Objective: The aim was to evaluate the natural history of a population with LAR of recent onset and the development of AR and asthma. Methods: A prospective 10-year follow-up study with initial cohorts of 194 patients with LAR of recent onset and 130 healthy controls is being undertaken. A clinical-demographic questionnaire, spirometry, skin prick test, and specific IgE to aeroallergens were done yearly. Nasal allergen provocation tests with Dermatophagoides pteronyssinus, Alternaria alternata, Olea europea, and a mix of grass pollen were performed at baseline and after 5 years. Results: At disease onset, most of the patients with LAR had moderate-to-severe persistent-perennial rhinitis; conjunctivitis and asthma were the main comorbidities (51.1% and 18.8%, respectively), and D pteronyssinus was the most relevant aeroallergen (51.1%). After 5 years of follow-up, a worsening of rhinitis was detected in 26.2%, with an increase in symptom persistence and severity, and new associations with conjunctivitis and asthma. Atopy was detected by skin prick test and/or serum specific-IgE in patients with LAR (6.81%) and in controls (4.5%). Conclusions: This study shows a similar rate of development of systemic atopy in LAR and controls, which suggests that LAR is an entity well differentiated from AR. To determine the natural course of LAR more precisely, this study is in progress to complete 10 years of follow-up. [Copyright &y& Elsevier]

Local allergic rhinitis (LAR) is a localized nasal allergic response in the absence of systemic atopy characterized by local production of specific IgE (sIgE) antibodies, a TH2 pattern of mucosal cell infiltration during natural exposure to aeroallergens, and a positive nasal allergen provocation test response with release of inflammatory mediators (tryptase and eosinophil cationic protein). Although the prevalence remains to be established, a number of patients previously given a diagnosis of nonallergic rhinitis or idiopathic rhinitis are now being classified as having LAR. Culprit allergens responsible include house dust mite, grass and olive pollens, and many others. For the diagnosis of LAR, neither skin prick testing nor determination of the presence of serum sIgE antibodies is useful, and a nasal allergen provocation test is needed to identify the culprit allergen or allergens. In a certain proportion of cases, local sIgE can be detected, and conjunctivitis, asthma, or both can be associated. Whether patients with LAR will have systemic atopy in the future is a matter of debate. Further studies are needed for examine the prevalence of this phenomenon in different areas, to improve the diagnostic methods to better identify these patients, and to develop therapeutic approaches, including the use of immunotherapy. [ABSTRACT FROM AUTHOR]

Background Patients previously given a diagnosis of nonallergic rhinitis (NAR) might have a new form of local allergic rhinitis (LAR) with local production of specific IgE antibodies and a positive response to a nasal allergen provocation test (NAPT). Objective We evaluated an NAPT protocol using multiple aeroallergens (NAPT-M) for the detection of polysensitization to several aeroallergens in patients with LAR. Methods NAPT-Ms with 2 different panels of aeroallergens for patients with perennial and seasonal rhinitis were performed in 25 patients with LAR and 25 patients with NAR whose disease was diagnosed by means of NAPTs 1 year earlier. The response to nasal challenge was evaluated based on subjective (nasal-ocular symptoms) and objective (acoustic rhinometry) parameters. Nasal levels of tryptase and eosinophil cationic protein were determined by means of immunoassay at baseline, 15 minutes, and 1, 2, and 24 hours after challenge. Results NAPT-Ms showed 100% concordance with the gold standard of NAPTs with a single aeroallergen. No false-positive or false-negative responses were detected. The use of NAPT-Ms achieved 75% reduction in the total number of visits required for final diagnosis in the NAR group (from 168 to 42 visits) and a 55% reduction in the LAR group (from 144 to 65 visits) compared with NAPTs with a single aeroallergen. Conclusions These results demonstrate that clinically relevant polysensitization to aeroallergens in patients with LAR occurred and that the NAPT-M is a useful, specific, sensitive, reproducible, and less time-consuming in vivo diagnostic test for the screening of patients with LAR. [ABSTRACT FROM AUTHOR]

Background: Nonallergic rhinitis (NAR) affects a significant number of patients in clinical practice. However, the different entities involved within NAR require further study. Once allergy has been ruled out, most of these patients are not usually followed up in allergy clinics, despite the persistence of rhinitis symptoms. Thus few data are available concerning the natural evolution of these patients. Objective: We sought to re-evaluate over time the severity, accompanying disorders, and possible allergen sensitizations in subjects with NAR. Methods: A representative sample of 180 patients given diagnoses of NAR during 2000-2004 was re-evaluated in 2007 by using sociodemographic and clinical questionnaires, spirometry, skin prick testing, and measurement of specific IgE to common aeroallergens. Results: Patients with NAR generally experienced worsening disease (52%), with an increase in the persistence (12%) and severity of nasal symptoms (9%) and new comorbidities (24%) over time. The most frequent comorbidities at the re-evaluation were asthma (increasing from 32% to 55%) and conjunctivitis (from 28% to 43%), followed by chronic rhinosinusitis. Sensitization to aeroallergens not present at the initial evolution was detected by means of skin prick testing, serum specific IgE measurement, or both in 24% of the patients. Conclusions: Persistent moderate-to-severe rhinitis associated with asthma, conjunctivitis, or both and sensitization to aeroallergens are likely to appear at a later date in adults initially given diagnoses of NAR. A periodic re-evaluation of these patients might therefore be necessary. [Copyright &y& Elsevier]

Background: Increased exposure to microbial products early in life may protect from development of atopic disorders in childhood. Few studies have examined the relationship of endotoxin exposure and pet ownership on atopy and wheezing during infancy. Objective: Evaluate relationships among high endotoxin exposure, pet ownership, atopy, and wheezing in high-risk infants. Methods: Infants (n = 532; mean age, 12.5 ± 0.8 months) with at least 1 parent with confirmed atopy were recruited. A complete medical history and skin prick testing to foods and aeroallergens were performed at age 1 year. House dust samples were analyzed for endotoxin. Results: Prevalences of wheezing were not independently associated with dog or cat ownership or endotoxin levels. Percutaneous reactivity to at least 1 allergen was observed in 28.6% of infants. Univariate analyses showed significant associations of any wheezing, recurrent wheezing, and recurrent wheezing with an event with daycare attendance, number of siblings, respiratory infections, maternal smoking, and history of parental asthma. Logistic regression adjusting for the latter variables showed that recurrent wheezing (odds ratio, 0.4; 95% CI, 0.1-0.9) as well as 2 other wheeze outcomes were significantly reduced in homes with high endotoxin exposure in the presence of 2 or more dogs. Conclusion: Pet ownership or endotoxin did not independently modify aeroallergen sensitization or wheezing during infancy. However, high endotoxin exposure in the presence of multiple dogs was associated with reduced wheezing in infants. Clinical implications: A home environment with many dogs and high levels of endotoxin may be conducive to reduced wheezing in infancy. [Copyright &y& Elsevier]