Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU
A 35-year-old African American male is referred to the allergy clinic for evaluation of allergic rhinitis for 4 years. He first developed nasal congestion, discharge, sneezing and itching 4 years ago when he moved from Florida to Alabama. He has taken Zyrtec-D (cetirizine, pseudoephedrine) daily during that period with partial relief and has occasionally used Flonase. The patient has never had allergy skin testing before. He was initially seen at the clinic last week while still taking Zyrtec (changed from Zyrtec-D by his insurance) and Amitriptyline, and the skin prick testing was postponed. He was asked to stop Zyrtec and Amitriptyline 5 days before the test and was prescribed Flonase (fluticasone).
Past medical history (PMH)
Rhinitis, migraine headache.
Medications
Medications
Zyrtec (cetirizine), amitriptyline (both stopped 5 days ago), Flonase (intranasal fluticasone)
Social history (SH)
Social history (SH)
Accountant. No tobacco use, no pets.
Physical examination
Stable vital signs (VSS). HEENT: Pale, boggy turbinates. Chest: CTA (B).
What diagnostic test would you suggest?
What diagnostic test would you suggest?
Skin prick testing.
Amitriptyline has an antihistamine effect, and both Amitriptyline and Zyrtec had to be stopped 5 days prior to testing.
The skin prick testing was negative for trees, grass, weeds, molds and indoor allergens (1-35 pricks). The histamine control was positive which indicated an adequate skin reaction. If the histamine control is negative in a patient on antihistamine, the reason could be that the patient is still taking the medication.
Skin test sheet. Image source: Dr. Stokes, Creighton University Division of Allergy & Immunology, used with permission (click to enlarge the image).
Diagram of skin prick testing (click to enlarge the image).
What is the most likely diagnosis?
Amitriptyline has an antihistamine effect, and both Amitriptyline and Zyrtec had to be stopped 5 days prior to testing.
The skin prick testing was negative for trees, grass, weeds, molds and indoor allergens (1-35 pricks). The histamine control was positive which indicated an adequate skin reaction. If the histamine control is negative in a patient on antihistamine, the reason could be that the patient is still taking the medication.
Skin test sheet. Image source: Dr. Stokes, Creighton University Division of Allergy & Immunology, used with permission (click to enlarge the image).
Diagram of skin prick testing (click to enlarge the image).
What is the most likely diagnosis?
Non-allergic rhinitis.
What questions would you ask to confirm the diagnosis of non-allergic rhinitis?
What questions would you ask to confirm the diagnosis of non-allergic rhinitis?
The patient was asked if he reacts to strong odors, perfumes, smoke and temperature changes. He reported nasal symptoms with strong odors and perfumes, predominantly manifested by increased nasal discharge.
Was there any seasonal variation in his nasal symptoms?
Was there any seasonal variation in his nasal symptoms?
No. Nasal discharge was persistent throughout the year.
Typically, allergic rhinitis is worse during the pollen season corresponding to the patient's allergies: spring for trees, summer for grass, fall for weeds, and year round for molds and indoor allergens.
Did he get worse after stopping Zyrtec (cetirizine)?
Typically, allergic rhinitis is worse during the pollen season corresponding to the patient's allergies: spring for trees, summer for grass, fall for weeds, and year round for molds and indoor allergens.
Did he get worse after stopping Zyrtec (cetirizine)?
No.
Typically, patients with allergic rhinitis report symptom worsening after stopping antihistimines. Zyrtec has no effect in patients with non-allergic rhinitis. Our patient reported a partial relief with Zyrtec-D because of the pseudoephedrine component rather than cetirizine.
How would you treat this patient with non-allergic rhinitis?
Typically, patients with allergic rhinitis report symptom worsening after stopping antihistimines. Zyrtec has no effect in patients with non-allergic rhinitis. Our patient reported a partial relief with Zyrtec-D because of the pseudoephedrine component rather than cetirizine.
How would you treat this patient with non-allergic rhinitis?
Flonase (fluticasone) should be continued.
Atrovent 0.03% nasal spray PRN bid was added since nasal discharge was the most bothersome symptom.
He was advised to use nasal saline rinses and to follow-up with us in 3 months. A CT scan of the sinuses was ordered to rule out an anatomical abnormality.
Final diagnosis
Atrovent 0.03% nasal spray PRN bid was added since nasal discharge was the most bothersome symptom.
He was advised to use nasal saline rinses and to follow-up with us in 3 months. A CT scan of the sinuses was ordered to rule out an anatomical abnormality.
Final diagnosis
Non-allergic rhinitis.
What did we learn from this case?
What did we learn from this case?
Intranasal anticholinergic (ipratropium) has a rapid onset of action (3-4 hours, similar to intranasal antihistamines) and can be used for for episodic rhinitis.
Ipratropium reduces rhinorrhea but is otherwise ineffective for congestion and other symptoms of AR.
Atrovent can cause extreme nasal dryness and therefore should be used PRN by most patients rather than continuously.
Treatment Options for Allergic Rhinitis (AR) and Non-Allergic Rhinitis (NAR) (click to enlarge the image).
Ipratropium reduces rhinorrhea but is otherwise ineffective for congestion and other symptoms of AR.
Atrovent can cause extreme nasal dryness and therefore should be used PRN by most patients rather than continuously.
Treatment Options for Allergic Rhinitis (AR) and Non-Allergic Rhinitis (NAR) (click to enlarge the image).
Oral antihistamines are ineffective for non-AR. Intranasal antihistamines however, are approved for vasomotor rhinitis (non-AR) which makes them a good option for patients with mixed rhinitis (AR/non-AR).
References
Guidelines Updated for Diagnosis and Treatment of Rhinitis. Laurie Barclay. Medscape.
The Diagnosis and Management of Rhinitis: An Updated Practice Parameter. The Journal of Allergy and Clinical Immunology, Volume 122, Issue 2, Supplement (August 2008).
Nonallergic rhinitis, CCJM 2012 review.
Image source: Wikipedia, a Creative Commons license.
Allergic Rhinitis: A Short Review
Mind Maps: Allergic Rhinitis
The Diagnosis and Management of Rhinitis: An Updated Practice Parameter. The Journal of Allergy and Clinical Immunology, Volume 122, Issue 2, Supplement (August 2008).
Nonallergic rhinitis, CCJM 2012 review.
Image source: Wikipedia, a Creative Commons license.
Allergic Rhinitis: A Short Review
Mind Maps: Allergic Rhinitis
Got allergies? Maybe it's actually non-allergic rhinitis. USA Today, 2010.
"Allergic" Reactions in Adults May Be Vasomotor or Nonallergic Rhinitis. WSJ, 2011.
Management of recalcitrant nasal congestion in chronic nonallergic rhinitis: fluticasone, azelastine, and capsaicin. AAAAI Ask the Expert, 2011.
Published: 08/25/2008
Updated: 12/23/2012
Management of recalcitrant nasal congestion in chronic nonallergic rhinitis: fluticasone, azelastine, and capsaicin. AAAAI Ask the Expert, 2011.
Published: 08/25/2008
Updated: 12/23/2012
3 comments:
Is it possible to have eye symptoms with non allergic rhinitis? I live in Atlanta, GA and had severe eye symptoms during this pollen season in the spring. I have had allergy testing, but all came back negative. The doctor diagnosed nonallergic rhinitis, but had no answer for the eye symptoms.
Any ideas?
Local allergic rhinitis is a diagnostic possibility.
In this case the patients have nose and eye symptoms with exposure to allergens but both the skin test and the blood test are negative for allergies.
What are treatment options for local allergic rhinitis?
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