|Year : 2016 | Volume
| Issue : 2 | Page : 37-41
Common Allergens noticed in patients with allergic rhinitis and asthma at a tertiary care centre in Western Saudi Arabia
AJ Aburiziza1, O Marglani2, SA Raza3, MJ Gazzaz3, I Herzallah3, D Rednah4
1 Deptartment of Allergy, King Abdullah Medical City (KAMC), Mecca, Saudi Arabia
2 ENT Department, King Abdullah Medical City (KAMC), Mecca, Saudi Arabia
3 ENT Department King Abdullah Medical City (KAMC), Mecca, Saudi Arabia
4 Student, Umm-AlQura University, Mecca, Saudi Arabia
|Date of Web Publication||6-Jan-2020|
King Abdullah Medical city (KAMC) Associate Professor
Source of Support: None, Conflict of Interest: None
Introduction and Objectives: Skin testing has been performed over decades to diagnose allergic disorders in clinical practice. Its safety has been well established. Skin prick test (SPT) is usually done by placing and testing for multiple allergen extracts on the skin preferably forearm. SPT was done to know IgE sensitization in patients with Allergic rhinitis and Asthma, attending allergy clinic during a one-year period.
Design and Setting: A retrospective chart review was done and an Institutional Review Board approval was obtained.
Patients and Methods: In this study skin prick test was performed using 24 allergen extracts on one hundred and twelve patients (112) with Allergic Rhinitis and Asthma at a tertiary care centre, Mecca Saudi Arabia between June 2012-July 2013.
Results: Eighty two (73.2%) patients had a positive skin prick test. Dust mite Dermatophagoides Pteronyssinus (DP), Dermatophagoides Farinae (DF) were the most common allergens and Mimosa was the least.
Conclusion: The Skin prick test is cost effective, most convenient and easy to perform test in diagnosing IgE mediated allergy.
Keywords: Allergens, aeroallergens, allergic rhinitis, asthma, dust mite, pollen, skin prick test
|How to cite this article:|
Aburiziza A J, Marglani O, Raza S A, Gazzaz M J, Herzallah I, Rednah D. Common Allergens noticed in patients with allergic rhinitis and asthma at a tertiary care centre in Western Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg 2016;18:37-41
|How to cite this URL:|
Aburiziza A J, Marglani O, Raza S A, Gazzaz M J, Herzallah I, Rednah D. Common Allergens noticed in patients with allergic rhinitis and asthma at a tertiary care centre in Western Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2016 [cited 2022 Nov 30];18:37-41. Available from: https://www.sjohns.org/text.asp?2016/18/2/37/275261
| Introduction|| |
Since it was introduced in the early sixties of the 19th Allergic rhinitis (AR) and Asthma are diseases which affect upper and lower airways in which there is hyper- reactive airway mucosa and sometimes episodes of acute exacerbation . Both conditions affect quality of life, school attendance, as well as work performance. The presence of one disease increases the possibility of the other . Up to 40% of AR patients will develop asthma and 80%-85% of asthmatics will also have AR.1 As per the ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines, AR patients should be evaluated for asthma and vice versa.
The incidence of upper and lower respiratory allergy has increased globally posing a heavy burden on health care systems . The prevalence of chronic allergic diseases have increased in Saudi Arabia up to three times in younger age groups . For optimal efficacy, it is necessary to treat both the conditions according to severity of the disease and its co-morbidities. It is known that Skin prick test (SPT) is the most widely used allergy test and can be performed during the initial consultation with a variety of allergens. What is less known is the type of allergens causing these disease in this particular region.
| Objectives|| |
This study aimed at finding out the common sensitizing allergens in patients with AR and Asthma attending allergy clinic. Our city is located where the climate is hot and humid and only a handful of studies have been done as per literature search. Hence, there was a need to perform this study in this area. The results of the SPT to different allergens have been analyzed. Patients were grouped into 3 categories: asthma, AR and both.
| Subjects and Methods|| |
A retrospective chart review was done on 112 consecutive patients who were referred to our allergy clinic with the diagnosis of AR, Asthma or both during the period from June 2012 to July 2013. Institutional Review Board (IRB12-022/2013) approval was obtained and complete patient confidentiality was maintained. The results of SPT to 24 different airborne allergens were selected based on patients history and common allergen of the region were analyzed (Stallergenes, France) The allergens were divided into various groups: weed antigens, tree, grasses, different Fungal molds, insect origin, animal, and weeds. A detailed history of symptoms and the presence of possible sources of allergens at home or work were documented. Normal saline and histamine served as negative and positive controls respectively. None of the patients were on any medications suppressing the immune system and all antihistamines were stopped at least 7 days prior to testing. Exclusion criteria included the presence of dermatographism, food allergy, or a negative histamine reaction.
Charts were also reviewed for Radioallergosorbent test (RAST) results whenever ordered. In our practice, we don’t have a fixed protocol for performing RAST, although we tend to order it more often in negative SPTs to confirm the diagnosis. Data entry was done with Microsoft Excel as the graphing software. Statistical analyses were performed using SPSS 14.0 statistical software for Windows (SPSS Inc, Chicago, IL, USA). The significance level was set at P< .05.
| Results|| |
Out of the one hundred and twelve patients included in the study; 51.8% were males and 48.2% were females. Age ranged from 2 to 69 with a mean age of 27.73 years. Exclusive AR was present in 75 patients (67%), exclusive asthma was present in 19 patients (17%), while both conditions were diagnosed in 18 patients (16%). Patients were categorized as AR, asthma, or both according to the diagnosis found in their medical records. Amongst all patients (73.2%) 82 had a positive SPT while 30 subjects (26.8%) had a negative result for all studied antigens In total, RAST was reported in 30 out of 112 cases. Out of the 82 patients who had a positive SPT, sixteen patients had undergone RAST. Only 7 of them (43.7%) had positive RAST, while the remaining 9 patients (56.3%) had negative RAST. On the other hand, out of the 30 patients who had negative SPT, RAST was done in 14 patients with a positive result in 6 (42.8%) and a negative outcome in 8 cases (57.2%) .
The most common allergens in the positive SPT group (73.2%) (82 patients) were: Dust mite Dermatophagoides Pteronyssinus (DP) (50%), Dermatophagoides Farinae (DF) (46.3%), cat (34.1%), cockroach (18.3%), grass- mix-Russian thistle (14.6%), and aspergillus (6.1%) In the exclusive AR group, the most common allergen was DP 59.3%, while in the exclusive asthma group the most frequent antigens were Russian thistle, Cockroach and Mugworth (16.7% each) .
The most common symptoms in general were runny nose, nasal blockage, nasal itching, and cough [Table 1]. The most common symptom in DP and DF positive patients was runny nose, being 41.5% and 47.4% respectively. However, it was cough (42.9%) for cat allergen positive patients and nasal blockage (66.7%) for cockroach positive subjects.
|Table l: The relationship between the most common symptoms and antigen positive patients|
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| Discussion|| |
It is estimated that 35 million people suffer from AR in America. The prevalence of asthma worldwide ranges from 0.2%-25% . In Saudi Arabia, the prevalence of chronic rhinitis in children was found to be as high as 26%, 62% of them were allergic based on SPT. Asthma prevalence increased from 8 to 23% . Allergic diseases in Saudi Arabia are increasing due to environmental and aerobiological factors as per recent studies . The environmental factors like agricultural and irrigation development, the greening and planting of trees are allergenic. The high concentration of dust, large amount of smoke from cars, industrial air pollution and the imported furniture rich in organic matter also contribute to allergic diseases. It appears to be increasing in summer months and declining in winter. Exposure to air conditioning is also another contributing factor ,.
Allergic SPT is a safe, reliable, simple, and cost effective way to diagnose allergy. Other workups like IgE level and (RAST) are in vitro tests to determine the presence of allergen-specific IgE antibodies. Additionally, serial end-point titration test (SET) has been used in diagnosing AR and asthma in allergy clinics.
SPT was first described in 1926 . It has the advantages of ease of administration and absence of false positives, but the degree of reactivity is difficult to measure. The reading of skin reactivity is usually done on a subjective 0 to 4 basis. A positive skin prick denotes the presence of IgE antibodies in patients who are exposed to allergy and is considered a useful screening test. RAST advantages include no risk to the patient, quantitative results, and low incidences of false-positive results. Both SPT and RAST, however, appear to miss some cases of allergy (low reactors) and their use appears to complement one another, as can be seen in our results.
Advantages of SET(Skin End Point Titration) include a better reproducibility (standardization) and a (semi) quantitative result that can be used to calculate customized starting doses of specific immunotherapy. Additionally, false negative results are lower than other techniques and hence, less incidence of missed allergens. The customization of skin testing extract vials for treatment is thought to account for the low reaction rate, allowing a safe, rapid escalation to an appropriate treatment dose. Disadvantages include a longer patient testing time and a greater amount of time needed to learn the technique .
Reviewing the literature through PubMed, we compared our study with some of the other studies from Saudi Arabia. This was done according to the type of the allergen and the number of patients sensitized [Table 2].
|Table 2: Comparison between various studies in the kingdom and our study|
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House dust mite has long been known to cause AR and asthma. House dust is a complex mixture of animals, fungi, algae, insect debris and human epithelial scales. DP and DF are the dominant dust mite species worldwide. They are universal, present throughout the year and give rise to allergic symptoms. Among our study population, we have found DP and DF to be the commonest allergens with a prevalence of 50% and 46.3% respectively. Even in the United States, dust mites were similarly noted as common allergens in AR (up to 46%), which is comparable to our study results . In Saudi Arabian studies it was noted that DP and DF was seen in 71.8% of the adult population in Riyadh and 30% in the Eastern province ,. This wide range in sensitization could be due to cross reactivity between DP and DF and tropical, subtropical and humid climatic variations .
The prevalence of cat allergy is also present in this part of the world. Pet ownership is on the rise reasons with subsequent rampant spread of allergen in the environment. Cat allergy in our series was 34.1%. In other studies done in Saudi Arabia, the results varied between 17.1 and 17.4% . The major cat allergen belongs to the group of secretoglobins, which spreads via clothes and secretions. Moreover, cat allergens are ubiquitous and may be found in environments even where cats are absent.
Cockroach allergy has increased over the years. It is known to cause allergy in the lower socioeconomic group worldwide . Cockroach faeces are known to be allergenic. In our study, the prevalence of cockroach allergy was 18.3%. This compares favorably to the results of study done in Riyadh in 2004 (17.1%). However, cockroach allergy was found to be as high as 35% in Eastern region in 1996 among 1159 tested subjects. The explanation of this difference is not clear, perhaps related to sample size, or due to time and location variances between the studies done by others and our study ,.
Pollen allergens are abundant in the ambient atmosphere. It is estimated that they cause 15-20% of the allergic diseases of the nose and lungs . Many pollens are released in dry and hot climates and hence the seasonal variations of the symptoms. In our series, we have noted Russian thistle to be the commonest, followed by Bermuda grass. A study in Riyadh has shown that 59.3% of the adult population is sensitized to Bermuda grass,8 and in another study it was 29% . On the other hand, Amaranthus viridis, Plantago spp., Chenopodium album, Ricinus communis, Rumex vesicarius, Juniperus spp., Parkinsonia aculeata, Prosopisspp., and Phoenix dactylifera were the most frequent pollen types noted in another Saudi study conducted in Riyadh ,.
A study coming from Abha, Saudi Arabia about the airborne pollen grain types present in air of showed that Poaceae is the commonest and represented 55.1% of total pollen, and that Pollen grains were found throughout the year. July represented the highest peak of pollen number and also the highest pollen taxa, it was also found that the pollen concentration is positively correlated with temperature and negatively correlated with rainfall, relative humidity and wind velocity. May- September represented the months of highest pollen number (95% of total pollen) found around the city .
Fungal allergens are thought to be the most abundant in nature. As they are less than 10 micron in diameter, deposition in upper and lower airway is common. The allergenic moulds are produced asexually and most of them are indoor allergens. In our series, the common moulds were aspergillus (6.1%) penicillum 2.4% and Candida 2.4%. Conversely, Cladosporium Smuts spores, Colored basidiospores, Alternaria, Ulocladium and Drechslera were the dominant types in Riyadh. Cladisporium, Penicillium, Aspergillus and Alternaria were also noted ,. This could be explained by the variation in the fungal antigens tested or by the geographical distribution of these antigens inside the Kingdom of Saudi Arabia and relationship to humidity and other environmental factors.
| Conclusion|| |
We confirm that SPT is the cost effective, most convenient and easy to perform test for patients attending allergy clinic. In our series, we have found that Dust mite was the most common allergen and Mimosa was the least common. However, our study did not isolate the different types of AR and asthma. We have found that the positivity to DP and DF was predominant even in cases where RAST was done. We also found RAST and SPT to complement each other in diagnosing allergy. We could not prove the superiority of one in comparison to the other, as RAST was not done in all cases. This study represents the data of the most common allergens in western Saudi Arabia, which could be a useful reference to counsel patients with AR and Asthma. Nevertheless, we recommend further prospective studies with larger sample size which would be a useful reference in dealing with these sorts of patients in this particular region.
A special thank you goes to those who contributed to this paper: Dr. Sohail Bajammal, Research Director and CEO, KAMC, Makkah. Dr. Soha Almorsy and Dr. Doaa Abdelmoety, research consultants for their valuable comments and guidance in preparing the manuscript, Khalid Al Matrafy medical graduate and Eilaf Fallatah medical student who helped us with data entry.
| References|| |
Nathan RA. Management of patients with allergic rhinitis and asthma. Literature Review. South Med J.
Basak P, Arayata R, Brensilver J. Prevalence of specific aeroallergen sensitivity on skin prick test in patients with allergic rhinitis in Westchester County. Internet J Asthma Allergy Immunol.
Al Frayh AR, Shakoor Z, Gad El Rab MO, Hasnain SM. Increased prevalence of asthma in Saudi Arabia. An Allergy Asthma Immunol.
Al Anazy FH, Zakzouk SM. The impact of social and environmental changes on allergic rhinitis among Saudi children A clinical and allergological study. Int J Pediatr Otorhinolaryngol.
Koshak EA, Daghistani KJ, Jamal TS, Backer WS. AllergyWorkup in Allergic Rhinitis at Jeddah, Saudi Arabia. Internet J Health.
Boyles Jr JH. A comparison of techniques for evaluating IgE-mediated Allergies. Ear Nose Throat J.
Nadarajah R, Rechtweg JS, Corey JP. Introduction to serial endpoint titration. Immunol Allergy Clin North Am
Almogren A. Airway allergy and skin reactivity to aeroallergens in Riyadh. Saudi Med J.
Suliaman FA, Holmes WF, Kwick S, Khouri F, Ratard R. Pattern of immediate type hypersensitivity reactions in the Eastern Province, Saudi Arabia. Ann Allergy Asthma Immunol.
Hasnain SM, Al-Frayh AR, Subiza JL, Fernández-Caldas E, Casanovas M, Geith T, et al. Sensitization to indigenous pollen and molds and other outdoor and indoor allergens in allergic patients from Saudi Arabia, United Arab Emirates, and Sudan. World Allergy Organ J.
Prakash O and Rao SP: Allergens in India: An overview. In: Shaikh WA Editor, Allergy and Asthma. A tropical view. Indian J Clin Pathol.
2001; P 22-31.
A-Suwaini AS, Bahkali AH, Hasnain SM. Airborne viable fungi in Riyadh and allergenic response of their extracts. Department of Biological & Medical Research, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia. Mycoses.
Alwadie H. Pollen concentration in the atmosphere of Abha city, Saudi Arabia and its relationship with meteorological parameters. J Applied Science.
[Table 1], [Table 2]