Allergic Rhinitis
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Drs. Plaut and Valentine (Nov. 3 issue)1 did not mention the use of saline nasal irrigation for the patient with seasonal allergic rhinitis. The student described in the case vignette wanted to avoid drowsiness and dry mouth. Nasal irrigation makes symptoms more tolerable and is an excellent addition to nasal corticosteroids.2,3,4
At the very least, it helps reduce the mucus to which the nasal inhaled steroids adhere. A controlled trial showed a significant improvement in symptoms.2
Patricia E. Boiko, M.D., M.P.H.
Factoria Medical Center
Bellevue, WA 98006
References
Plaut M, Valentine MD. Allergic rhinitis. N Engl J Med 2005;353:1934-1944.
Tomooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation. Laryngoscope 2000;110:1189-1193.
Garavello W, Romagnoli M, Sordo L, Gaini RM, Di Berardino C, Angrisano A. Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: a randomized study. Pediatr Allergy Immunol 2003;14:140-143.
Georgitis JW. Nasal hyperthermia and simple irrigation for perennial rhinitis: changes in inflammatory mediators. Chest 1994;106:1487-1492.
To the Editor: Plaut and Valentine indicated that the sensitivity and specificity of in vitro tests for serum IgE antibody to allergens are equal to that of skin testing. The sensitivity and specificity of in vitro serology differ for various allergens and are not equivalent to skin-test methods.1 Food allergens have been most comprehensively studied to determine the clinical sensitivity of tests for specific IgE antibodies, and IgE thresholds have been determined that define 95 percent probability of a negative challenge.2 However, equivalent decision levels with such clinical predictions are not available for outdoor aeroallergens, and there are no studies that directly compare diagnostic equivalence of in vitro testing with that of in vivo testing.3 The immediate hypersensitivity test by the skin-prick method with wheal and flare measurement still is the gold standard for diagnosis of IgE-mediated aeroallergen allergy because of its unparalleled sensitivity.1 Thus, testing for serum IgE antibody and the immediate hypersensitivity skin test are both acceptable for determining respiratory allergies, but they are not equivalent.4
Lenora M. Noroski, M.D.
Carla Davis, M.D.
Baylor College of Medicine
Houston, TX 77030
Lnoroski@bcm.tmc.edu
References
Hamilton RG, Franklin Adkinson N Jr. In vitro assays for the diagnosis of IgE-mediated disorders. J Allergy Clin Immunol 2004;114:213-225.
Sampson HA, Ho DG. Relationship between food-specific IgE concentrations and the risk of positive food challenges in children and adolescents. J Allergy Clin Immunol 1997;100:444-451.
Stokes J, Kessler R, Philip G, Casale TB. Ragweed skin test responsiveness correlates with specific immunoglobulin E levels. Allergy Asthma Proc 2005;26:103-107.
Hamilton RG, Adkinson NF Jr. Clinical laboratory assessment of IgE-dependent hypersensitivity. J Allergy Clin Immunol 2003;111:Suppl:S687-S701.
The authors reply: Dr. Boiko advocates the use of saline nasal irrigation. Although saline may be useful as a palliative treatment in allergic rhinitis,1 it is used more commonly in nonallergic rhinitis (bacterial rhinitis and vasomotor rhinitis).2 Since its effect as an active intervention might be indistinguishable from that of placebo, we chose not to include saline in our list of pharmacologic agents.
Drs. Noroski and Davis raise the question of whether in vitro tests for serum IgE antibody are as sensitive and specific as skin testing. They have accurately noted that more data would be useful to provide a clearer comparison of the sensitivities of in vivo and in vitro assays with respect to outdoor aeroallergens. It is important to note that both in vivo assays (typically skin-prick tests) and in vitro assays have sufficient sensitivity to provide comparably useful clinical information for allergic rhinitis. The two main approaches to allergen skin testing are by the prick and intradermal routes. Intradermal testing has greater sensitivity but lower specificity than prick testing, and thus does not appear to be more clinically useful in allergic rhinitis than prick or in vitro testing. Skin-prick testing is moderately more sensitive but less specific than radioallergosorbent testing. More recently, newer variants of the radioallergosorbent test and the enzyme-linked immunosorbent assay have been developed that are more sensitive than the original radioallergosorbent test. These newer in vitro tests are only slightly less sensitive than skin tests,3 and their specificity may be greater.4 Thus, if either one or the other type of test has the advantage, it may result from lower cost or greater convenience, rather than sensitivity or specificity.
We also wish to clarify a statement in our original article. The use of a semicolon before the comment "increased intraocular pressure and posterior subcapsular cataracts have been reported in adults" may have inadvertently suggested that these complications have been reported only with intranasal beclomethasone, whereas they also have been reported with other nasal corticosteroids.
Marshall Plaut, M.D.
National Institute of Allergy and Infectious Diseases
Bethesda, MD 20892-6601
mplaut@niaid.nih.gov
Martin D. Valentine, M.D.
Johns Hopkins University School of Medicine
Baltimore, MD 21224
References
American Academy of Allergy, Asthma and Immunology. The allergy report. (Accessed February 23, 2006, at http://www.theallergyreport.com/.)
Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 1998;81:478-518.
Yunginger JW, Ahlstedt S, Eggleston PA, et al. Quantitative IgE antibody assays in allergic diseases. J Allergy Clin Immunol 2000;105:1077-1084.
Pastorello EA, Incorvaia C, Ortolani C, et al. Studies on the relationship between the level of specific IgE antibodies and the clinical expression of allergy. I. Definition of levels distinguishing patients with symptomatic from patients with asymptomatic allergy to common aeroallergens. J Allergy Clin Immunol 1995;96:580-587.
At the very least, it helps reduce the mucus to which the nasal inhaled steroids adhere. A controlled trial showed a significant improvement in symptoms.2
Patricia E. Boiko, M.D., M.P.H.
Factoria Medical Center
Bellevue, WA 98006
References
Plaut M, Valentine MD. Allergic rhinitis. N Engl J Med 2005;353:1934-1944.
Tomooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation. Laryngoscope 2000;110:1189-1193.
Garavello W, Romagnoli M, Sordo L, Gaini RM, Di Berardino C, Angrisano A. Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: a randomized study. Pediatr Allergy Immunol 2003;14:140-143.
Georgitis JW. Nasal hyperthermia and simple irrigation for perennial rhinitis: changes in inflammatory mediators. Chest 1994;106:1487-1492.
To the Editor: Plaut and Valentine indicated that the sensitivity and specificity of in vitro tests for serum IgE antibody to allergens are equal to that of skin testing. The sensitivity and specificity of in vitro serology differ for various allergens and are not equivalent to skin-test methods.1 Food allergens have been most comprehensively studied to determine the clinical sensitivity of tests for specific IgE antibodies, and IgE thresholds have been determined that define 95 percent probability of a negative challenge.2 However, equivalent decision levels with such clinical predictions are not available for outdoor aeroallergens, and there are no studies that directly compare diagnostic equivalence of in vitro testing with that of in vivo testing.3 The immediate hypersensitivity test by the skin-prick method with wheal and flare measurement still is the gold standard for diagnosis of IgE-mediated aeroallergen allergy because of its unparalleled sensitivity.1 Thus, testing for serum IgE antibody and the immediate hypersensitivity skin test are both acceptable for determining respiratory allergies, but they are not equivalent.4
Lenora M. Noroski, M.D.
Carla Davis, M.D.
Baylor College of Medicine
Houston, TX 77030
Lnoroski@bcm.tmc.edu
References
Hamilton RG, Franklin Adkinson N Jr. In vitro assays for the diagnosis of IgE-mediated disorders. J Allergy Clin Immunol 2004;114:213-225.
Sampson HA, Ho DG. Relationship between food-specific IgE concentrations and the risk of positive food challenges in children and adolescents. J Allergy Clin Immunol 1997;100:444-451.
Stokes J, Kessler R, Philip G, Casale TB. Ragweed skin test responsiveness correlates with specific immunoglobulin E levels. Allergy Asthma Proc 2005;26:103-107.
Hamilton RG, Adkinson NF Jr. Clinical laboratory assessment of IgE-dependent hypersensitivity. J Allergy Clin Immunol 2003;111:Suppl:S687-S701.
The authors reply: Dr. Boiko advocates the use of saline nasal irrigation. Although saline may be useful as a palliative treatment in allergic rhinitis,1 it is used more commonly in nonallergic rhinitis (bacterial rhinitis and vasomotor rhinitis).2 Since its effect as an active intervention might be indistinguishable from that of placebo, we chose not to include saline in our list of pharmacologic agents.
Drs. Noroski and Davis raise the question of whether in vitro tests for serum IgE antibody are as sensitive and specific as skin testing. They have accurately noted that more data would be useful to provide a clearer comparison of the sensitivities of in vivo and in vitro assays with respect to outdoor aeroallergens. It is important to note that both in vivo assays (typically skin-prick tests) and in vitro assays have sufficient sensitivity to provide comparably useful clinical information for allergic rhinitis. The two main approaches to allergen skin testing are by the prick and intradermal routes. Intradermal testing has greater sensitivity but lower specificity than prick testing, and thus does not appear to be more clinically useful in allergic rhinitis than prick or in vitro testing. Skin-prick testing is moderately more sensitive but less specific than radioallergosorbent testing. More recently, newer variants of the radioallergosorbent test and the enzyme-linked immunosorbent assay have been developed that are more sensitive than the original radioallergosorbent test. These newer in vitro tests are only slightly less sensitive than skin tests,3 and their specificity may be greater.4 Thus, if either one or the other type of test has the advantage, it may result from lower cost or greater convenience, rather than sensitivity or specificity.
We also wish to clarify a statement in our original article. The use of a semicolon before the comment "increased intraocular pressure and posterior subcapsular cataracts have been reported in adults" may have inadvertently suggested that these complications have been reported only with intranasal beclomethasone, whereas they also have been reported with other nasal corticosteroids.
Marshall Plaut, M.D.
National Institute of Allergy and Infectious Diseases
Bethesda, MD 20892-6601
mplaut@niaid.nih.gov
Martin D. Valentine, M.D.
Johns Hopkins University School of Medicine
Baltimore, MD 21224
References
American Academy of Allergy, Asthma and Immunology. The allergy report. (Accessed February 23, 2006, at http://www.theallergyreport.com/.)
Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 1998;81:478-518.
Yunginger JW, Ahlstedt S, Eggleston PA, et al. Quantitative IgE antibody assays in allergic diseases. J Allergy Clin Immunol 2000;105:1077-1084.
Pastorello EA, Incorvaia C, Ortolani C, et al. Studies on the relationship between the level of specific IgE antibodies and the clinical expression of allergy. I. Definition of levels distinguishing patients with symptomatic from patients with asymptomatic allergy to common aeroallergens. J Allergy Clin Immunol 1995;96:580-587.