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Table of Contents
ORIGINAL ARTICLE
Year : 1998  |  Volume : 1  |  Issue : 1  |  Page : 27-33

Prevalence of allergic rhinitis among people living in Riyadh: A hospital based clinical and allergological study


1 Security Forces Hospital, Riyadh, Saudi Arabia
2 King Saud University, Riyadh, Saudi Arabia

Date of Web Publication16-Jun-2020

Correspondence Address:
M.D., F.R.C.S. Siraj M Zakzouk
Internal Security forces Hospital, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.286853

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  Abstract 


Two hundred fifty eight out of 403 adult patients with a clinical diagnosis of allergic rhinitis agreed to enter the study where clinical and allergological examination were carried out. Two hundred eleven were Saudis and 47 were non-Saudis living in Riyadh for the past 3 to 5 years who never had allergic symptoms while at theirrespective countries.
The aims of this work were to study the prevalence of allergic rhinitis among patients attending ear, nose and throat clinic, to identify the common allergens found,the patients life style, nationality and periodicity of the attacks in relation to aerobiological study carried out in the kingdom A comprehensive clinical history using a questionnaire were taken from all patients. All patients were skin tested with a standard set of 25 allergens selected according to local data from aerobiological studies and dust sample analysis in Saudi Arabia. The standard skin-prick test was used. Forty eight patients with no rhinological disease were skin tested as acontrol group.
Perennial symptoms were evident in 175 (68%) of the Saudi nationals while in expatriate only 12 cases (25.5%) showed perennial pattern and the rest were seasonal. Skin prick test (SPT) was positive in 176 (68.2%) to one or more of the skin test allergens. The common allergens were house dust mite, cat fur, cockroach,pollens i.e. Bermuda grass and chenopodia, acacia & rhizopus.
The study showed that allergic rhinitis is common among Saudis and non-Saudis living in Riyadh. There is a definitive pattern of sensitivities influenced by imported flora. Cat sensitivity showed high prevalence due to increased presence of wild cat in the environment. Other environmental stimuli including temperature changes, odours, air conditioning, emotional upset and carpeting trigger the symptoms.

Keywords: Allergic rhinitis, Saudi Arabia, House dust mite, cat


How to cite this article:
Zakzouk SM, Al-Anazy FH, Aseri S. Prevalence of allergic rhinitis among people living in Riyadh: A hospital based clinical and allergological study. Saudi J Otorhinolaryngol Head Neck Surg 1998;1:27-33

How to cite this URL:
Zakzouk SM, Al-Anazy FH, Aseri S. Prevalence of allergic rhinitis among people living in Riyadh: A hospital based clinical and allergological study. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 1998 [cited 2022 Nov 30];1:27-33. Available from: https://www.sjohns.org/text.asp?1998/1/1/27/286853




  Introduction Top


Allergic rhinitis is a fairly common disease which seems to be on the increase throughout the world. About 10-20% of the population suffers from allergic rhinitis. [1],[2] Allergic rhinitis is an allergic an allergic reaction to substances released into the environment such as grass, pollens, dried faeces of the house dust mite, danders, fungal spores..etc. The amount of allergen challenge and the intensity of the resulting symptoms are affected by factors such as weather conditions, exercise, state of health and pollution.

The Kingdom of Saudi Arabia is a large country situated in the middle of the Arabian peninsula. It has considerable variation in geography, climate and life style. The rapid development of the country with urbanisation of the population, the changing nature of the environment, imported flora plants to the country, the increased pollution together with the high concentration of dust particles in the atmosphere and low humidity in Riyadh, contribute and increase the potential allergens.

The aims of this work were to study the prevalence of allergic rhinitis among patients attending the ear, nose and throat clinic, to identify the common allergens found, the patients life style, nationality, periodicity of the attacks in relation to aerobiological study carried out in the kingdom.


  Material and Methods Top


During one year period, 1711 patients attended our ear, nose and throat clinic. Four hundred three adult patients with a clinical diagnosis of allergic rhinitis wereseen (23.55%). Out of these, 258 patients, agreed to enter the study where clinical and allergological examination were carried out. Patients who refused to have skin test for allergy were excluded. Two hundred eleven were Saudis and 47 were non-Saudis living in Riyadh for the past 3 to 5 years. The non-Saudi patients claimed not to have had allergic symptoms while living in their respective countries. Forty eight patients with non-rhinological disease were used as a control group [Table 1].
Table 1: Patients characteristic

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A comprehensive clinical history using a questionnaire were obtained from all patients; this included socioeconomic status, duration of living in Riyadh, the onset of attack, periodicity, perennial or seasonal, presence of domestic animal in the house and types of houses including furniture.

The diagnosis of allergic rhinitis was based on history, clinical examination and allergy work up studies. Clinical examination included anterior rhinoscopy as well as nasal endoscopy using O degree endoscope. The appearance of nasal mucosa, presence of polypi, deviated nasal septum, state of turbinates, presence of discharge and its character were noted. Radiography of sinuses were done to all of the patients. CT scan was used for those patients with nasal polypi & suspected sinusitis.

All patients including the control group were skin tested with a standard set of 25 allergens selected according to local data from aerobiological studies and dust sample analysis in Saudi Arabia. [3],[4] These represent the most common regional allergens [Table 2]. The extract were supplied by ALK Laboratories, Copenhagen, Denmark, using standardised special purity (SQ) material wherever possible and some extract were supplied by Meridien Laboratories, USA. They were grouped into indoor inhalants (dust & animal danders), fungal spores, pollens and ingestants. The standard skin-prick test was used. Drops of the allergens were spaced on the forearm and the skin pricked with a fine blood lancet. Reactions were read after ten minutes and the wheel diameter recorded. A positive reaction was determined as a wheel diameter of 3 mm or more (greater than the negative control). A positive control with histamine dihydrochloride (I mgm/ml) and a negative control with saline were included in every patient.
Table 2: Panal of skin test allergens [zakzouk SM & Gad-El-Rab MO,1996]

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  Results Top


Two hundred fifty eight Saudi patients and 47 non- Saudis were included in this study. One hundred fifty two (58.9%) were males and 106 (41.1%) were females.The age range was between 17 to 45 years with the mean age of 29.5 years. The distribution of numbers and nationalities is shown in [Table 1]. The expatriate patients denied having any allergic symptoms while they were living in their respective countries and claimed to have developed allergic rhinitis when they came to live in Riyadh. Sixty four per cent of the Saudi nationals gave a positive family history of atopy.

The main presenting complaints were nasal irritation, recurrent episodes of sneezing, runny nose with alternating nasal blockage. With regard to the pattern of the disease, perennial symptoms were evident in 175 (68%) of the Saudi nationals while in expatriate only 12 cases (25.5%) showed perennial pattern and the rest had seasonal allergic rhinitis, seasonal. [Figure 1] shows the total number of patients seen each month and the number of allergic patient indicating a prevalence of 23.55%. Deviated nasal septum was noted in 154 (46%). The degree of deviation was varied. Correction of septal deformity was required in 69 patients while mild deviations were left alone.
Figure 1:

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Nasal polypi were found in 44 patients. CT scan was done in 184. They were required in cases of suspected sinusitis, polypi and headache, haziness and opacity of sinuses were noted in all of them. Nine cases with fungal sinusitis were proved by culture postoperatively.

Absence or diminished sensation of smell was noted in 82% of the patients. The number of patient with bronchial asthma as well was 18 (5%).

Skin prick test (SPT) was positive in 176 (68.2%) to one or more of the skin test allergens of the patients with allergic rhinitis. Eighty two rhinitis patients were skin test negative. The positive wheel diameter ranged from 3 to 12 mm, the smaller wheels were excluded by the definition of positivity. The histamine-postive wheels averaged 5.9 ± 1.41 mm for the 176 skin test positive patients and 5.54 ± 1,36mm for the 82 skin test negative rhinitis patients. The skin test negative control patients showed a histamine wheel size averaging 4.93 ± 1.45mm. The response was smaller than the rhinitis patients with p value of < 0.001 which is significant.

Aspirin sensitivity was noted to be associated with allergic symptoms in 29 patients (11.2%). This was according to history as there is no specific test for aspirin sensitivity. Reactions were more prominent to indoor and pollen allergens, 31% to bermuda grass, 29.4% to house dust mix and 30.2% to cat allergens, and 31.8% of patients to cockroaches. Reaction to food ingestants ranged between 3.9% to 18.2%. Reaction to fungi ranged between 2.4% to 7.5%, No significant differences were found between males and females regarding the frequency of positive reaction. Eosinophilia of more than 10% was found in 26% of SPT positive patients.

The pattern of reactions to different allergens is shown in [Table 3]. The common allergens were house dust mites, cat fur, cockroach, pollens i.e. Bermuda grass and chinopodia, acacia & rhizopus.
Table 3: The pattern of reaction to different allergens

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  Discussion Top


Allergic rhinitis is a fairly common disease seen at ear, nose and throat clinics. The clinical diagnosis of allergic rhinitis largely depends on patient’s history and laboratory tests.

The common allergens that produce allergic rhinitis are indoor and outdoor inhalants. The relative importance of allergens whether pollens, fungal spores or animal danders depends on various factors such as the relative humidity, people’s habits, type of housing ( old or new) and the use of air conditioning. The prevalenceof possible contribution of allergens of indoor origin (house dust mite, cockroaches, animal allergens and allergens of plants origin ) were studied in various regions of Saudi Arabia. [3],[4]

In this study the majority of patients (143) showed positivity for more than one allergen. Dust mite and cat fur form the most common group of allergens.

Carpets are commonly used in almost all houses in Saudi Arabia. Cats are sometimes kept in houses but not dogs. Cat allergens are found both indoor and outdoor. The cat allergens found in cat’s dander and saliva contribute to the inhalant allergens in Saudi Arabia. [5]

Riyadh has a dry atmosphere with a relative humidity of 10% most of the year. Sand storms occur from time to time carrying a lot of allergens with the sand.

Hasnain et al, 1989 [3] conducted aerobiological studies to evaluate allergenic fungal spores in the atmosphere of Riyadh using Burkard volumetric 7-day recording spore trap and culture plate technique. They found that the majority of these fungal spores belonged to dry- air spores of conidial fungi, originating from garbage and rubbish bins, stored fruits, vegetables and the like. Seasonal periodicities showed an increase concentrations in warmer months and declined in winter.

Outdoor allergens (pollens) in Riyadh showed double peaks of pollens grains; a spring peak in March, April and May and an autumn peak in October.[5]The most common belongs to chenopodiaceae (weed ), grasses, fungal spores as alternaria cladosporoides and aspergillus. Our study showed 32% of Saudi patients to have an increase in number of attacks during spring and autumn while 74% of the expatriates showed seasonal variations. This seasonal variation corresponds to a previous aerobiological studies. [3],[4] During winter months the number decreased to 17.%.

The two clinically important house dust mite (HDM) species, D. pteronyssinus and D .farinae are present with regional diversity in Saudi homes in levels exceeding threshold values for sensitisation.

Al-Frayh et al 1997 [5] reported the SPT results of 462 patients tested with D. pteronyssinus and D. farinae showing that up to 25.1% and 19.1% positive reactions were obtained by D. pteronyssinus and D. farinae respectively in asthmatic children in the mountainous region, while 56.3% positive reactions were obtained by D. farinae in coastal areas. In agricultural and dry regions, the figures were 7.6% and 12.6% respectively for D. pteronyssinus and D. farinae. However, 31% positive reactions to HDM reveal sensitisation of individuals (or those already sensitised) in the dry region (Riyadh)as well. They suggested that the possible explanation may be that a proportion percentage of the Riyadh population might have more exposure to a humid climate by frequent travel abroad and/or within the country.

Munir, 1994 [7] studied the environmental factors in Scandinavia and concluded that the concentration of mite allergens is lower in temperate climates than in humid, warm regions. Thus, the variations in the contents of dust mite species in different geographical regions can be attributed to climate and geography of the regions which, in turn, increases the risk factor for sensitive individuals, in the indoor environment.

In our studies, reaction to food allergens were detected in 37 (14.3%) of patients, six of them suffering from bronchial asthma as well. It has been reported that allergy to food is less common in patients with rhinitis alone compared to patients with rhinitis associated with asthma or eczema. Cross-section between some foods and pollens were all documented. [8] Iris germanica (orris root) was found in 12.8% of SPT positive patients. This is the plant material used in tooth paste, which could be ingested during teeth cleaning and provoke symptoms. [9]

Earlier studies by Sorensen et al. 1986 and Al-Shalan et al 1989 [10],[11], reported that 65.6% of Saudi patients with rhinitis had a positive skin reaction to one or more allergens. Zakzouk & Gad-El-Rab 1996 [9] reported that 66.3% of their study group showed positive skin reactions to a panel of allergens. In this study 68.2% showed positive reactions. These results are comparable to studies from other countries with completely different environmentaland climatic conditions. Eriksson 1987 [12] reported a frequency of 73.4% in Swedish patients with rhinitis, while Friedhoff et al. 1981 [13] identified 55% with positive skin reactions in Baltimore (U.S.A.).

Al-Anazy & Zakzouk, 1997 [14] in their study of the prevalence of allergic rhinitis in children in Riyadh concluded that the occurrence of allergic rhinitis in paediatric population is increasing probably due to the environmental changes in the country. Bermuda grass which grows extensively in Saudi environment and mesquite produce the most common reaction, as well as Chenopodacea and cockroach. Many children showed reaction to cat fur although they do not have cats in their houses. This is due to the presence of many wild cats in the city.

Rhizopus trees which were heavily implanted in the streets of Riyadh are now considered the explanation for the increased sensitivity of population.

This study showed that allergic rhinitis is common among Saudis and non-Saudis living in Riyadh. There is a definitive pattern of sensitivities influenced by imported flora. Cat sensitivity showed high prevalence due to the increased presence of wild cats in the environment. The concentration of HDM are influenced by geography and climate, and the humidity of the region in question, which, in turn, influences the sensitisation, pattern and degree of SPT reactivity.



 
  References Top

1.
Fireman P. Pathophysiology and pharmacotherapy of common upper respiratory disease. Pharmacotherapy 1993; 13 (Suppl 6): 101S-9S.  Back to cited text no. 1
    
2.
White M.V.,Kaliner M.A. Mediators of allergic rhinitis. J Allergy Clin Immunol 1992; 90: 699-704.  Back to cited text no. 2
    
3.
Hasnain S.M., Al-Frayh, A.R., Thorogood R., Harfi H.A. Wilson J.D. Seasonal periodicities of fungal allergens in the atmosphere of Riyadh. Ann Saudi Med 1989; 9:337-343.  Back to cited text no. 3
    
4.
Al-Frayh A.R., Reilly H., Harfi H.A., Hasnain S.M., Thorogood R, Wilson J.D. A 12month aerobiological survey of pollen in Riyadh. Ann Saudi Med 1989; 9: 443-447.  Back to cited text no. 4
    
5.
Al-Frayh A.R. Proceeding of the Symposium on Recent Advances in the diagnosis and Management of Allergic Disease, Riyadh, 9-11 January 1995.  Back to cited text no. 5
    
6.
Al-Frayh A.R., Hasnain S.M., Gad-El-Rab M.O., Schwartz B., Al-Mobairek K., AlSedairy S.T. House dust mite allergens in Saudi Arabia: Regional variations and immune response. Ann Saudi Med 1997; 17: 156-160.  Back to cited text no. 6
    
7.
Munir A.K.M. (I 995). Environmental factors influencing the levels of indoor allergens. Pediat Immunol 1995; 6 (suppl 7): 13-21.  Back to cited text no. 7
    
8.
Boccafogli A,, Vicentini L., Camerani A., et al. Adverse food reactions in patients with grass pollen allergic respiratory disease. Ann Aller 1994;73:301-308.  Back to cited text no. 8
    
9.
Zakzouk S.M., Gad-El-Rab M.O. A study of clinical and allergic aspects of rhinitis patients in Riyadh. Ann Saudi Med 1996,- 16: 550-553.  Back to cited text no. 9
    
10.
Sorensen H., Ashoor A.A., Maglad S. Perennial rhinitis in Saudi Arabia: a prospective study. Ann Aller 1986;56:70-80,  Back to cited text no. 10
    
11.
Al-Shalan A.A, Al-Frayh A., Reilly H., Al- Hussein K.A., Wilson J.D. Inhalant allergens in patients with allergic rhinitis in Riyadh. Ann Saudi Med 1989;9:331-336.  Back to cited text no. 11
    
12.
Eriksson N.E. Allergy screening in asthma and allergic rhinitis:which allergens should be used?. Allergy 1987;42:189-195.  Back to cited text no. 12
    
13.
Friedhoff L.R., Mayers D.A.,Bias W.E. et al. A genetic-epidemiologic study of human immune responsivness to allergens in an industrial population: 1. Epidemiology of reported allergy and skin test positivity.Am J Med Gen 1981; 9: 323-340.  Back to cited text no. 13
    
14.
Al Anazy F.H. & Zakzouk S.M. The impact of social and environmental changes on allergic rhinitis among Saudi children - A clinical and allergological study. Int J Pediatr Otorhinolaryngol 1997;42:1-9.  Back to cited text no. 14
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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