Manuscript
Published in Rhinology 44:86-, 2004
Seasonal non-allergic rhinitis (SNAR) – A new disease entity?
A clinical and immunological comparison between SNAR, seasonal allergic rhinitis and
persistent non-allergic rhinitis.
Anna Wedbäck1,
Håkan Enbom2, Nils E Eriksson1, Robert Movérare4 and nga
Malcus3 and
1Lung and
Allergy Clinic, County Hospital, Halmstad,
2ENT
Clinic, County Hospital, Halmstad
34ENT Clinic, Ängelholm Hospital, Ängelholm, Sweden.
4Pharmacia
Diagnostics AB and Department of Medical Sciences, Respiratory Medicine and Allergology,
Uppsala University, Uppsala, Sweden
Correspondence
Nils E Eriksson
Gaggegatan
17b
SE-30237
Halmstad
E-mail:[email protected]
Telephone: +46-35 129150
Fax: +46-35 130397
Allergic rhinitis, IgE, nasal provocations, non-allergic rhinitis, skin prick
test
Summary
We have earlier described a group of patients suffering from rhino-conjunctivitis
during the early pollen season, but with negative allergological investigation. The
present study aimed to evaluate this syndrome called Seasonal Non Allergic Rhinitis
(SNAR). Seventeen patients with SNAR were compared with 20 patients with seasonal allergic
rhinitis (SAR) and 13 patients with persistent non-allergic rhinitis (PNAR). They were
analyzed with skin prick tests (SPT) and nasal provocation tests (NPT) with pollen
extracts, and for IgE antibodies in serum and inflammation mediators in nasal lavage.
Daily symptoms and medicine consumption were recorded. Late reactions after SPT occurred
in two SNAR, eight SAR and two PNAR patients. Weak immediate and late reactions after NPT
were induced in 3/15 and 7/15 SNAR patients, respectively, and in 1/13 and 5/13 PNAR
patients. All SAR patients had immediate and 9/18 had late reactions. The total IgE levels
were lower in SNAR compared to SAR. In the SNAR group 1/15 was positive in Phadiatop.
Increased tryptase levels after NPT were only observed in SAR. The SNAR patients had high
daily symptom scores already before birch pollen season. Sneezing was more common in SNAR
and SAR than in PNAR; eye-symptoms more prominent in SAR than in SNAR or PNAR. SNAR seems
to be different from SAR and PNAR regarding immunological mechanism and symptom period. We
conclude that the cause of SNAR is unknown.
Non-infectious
rhinitis can be allergic or non-allergic. Allergic forms of rhinitis can be seasonal or
perennial (SG Johansson et al
2001) . Seasonal allergic
rhinitis (SAR), often called hay fever, is in Sweden caused by allergy towards pollen from
birch and other deciduous trees, with a symptom period in April - May, from grasses, with
symptoms mainly in June - July and from mugwort, with symptoms mainly in the month of July
- August.
Non-allergic
rhinitis, which is sometimes referred to as hyperreflectory rhinopathy or vasomotor
rhinitis, is usually regarded as a disease with perennial (persistent) nasal symptoms,
i.e. persistent non-allergic rhinitis (PNAR) (SG Johansson et al
2001) . In routine work at the
Lung and Allergy Clinic in Halmstad, however, a number of patients have been observed,
having seasonal rhino-conjunctivitis symptoms, who at clinical allergy investigation
showed no signs of pollen allergy, in spite of the fact that they reported a symptom
period mainly coinciding with the early pollen season. In an earlier study, 86 patients
with similar case history were compared with birch pollen allergic patients and patients
with PNAR. The term Seasonal Non-Allergic Rhinitis (SNAR) was used to describe this new
disease entity (NE Eriksson 1991)
. It
was concluded from that study that SNAR had more characteristics in common with PNAR than
with SAR. The causes of the strictly seasonal symptoms of this syndrome are, however, not
evident.
Pollen-borne
allergic rhinitis is a typical example of an IgE-mediated allergy. The symptoms starts
when allergens bind to specific IgE-antibodies on the surface of mast cells leading to the
release of tryptase, cytokines, leukotrienes and prostaglandins. This follows by an
inflammation cascade with infiltration of T helper cells and eosinophils into the airways,
a hallmark of the allergic late phase reaction (S Montefort et al 1994)
.
Activated eosinophils produce toxic proteins such as eosinophil cationic protein (ECP)
that cause tissue destruction (P
Venge et al 1999) .
The role of
neutrophils in allergic inflammation is unclear. The neutrophil-derived myeloperoxidase
(MPO) is primarily elevated in nasal lavage during exposure to non-specific irritants or
during airway infections (M Ahman et al 2001; C
Bachert et al 2001) .
The aim of the present study was to further evaluate the disease entity SNAR by
examining and comparing three groups of patients with diagnosis of SNAR, SAR and PNAR. The
groups were compared regarding symptoms and drug consumption during the birch and grass
pollen seasons. Skin prick test (SPT) was performed with several pollen allergens, and
nasal provocation test (NPT) with extracts of birch or timothy pollen. Furthermore, serum
concentrations of total IgE and specific IgE antibodies to various pollen allergens were
measured, as well as tryptase, ECP and MPO in nasal lavage before and after NPT.
From the
patients register at the Lung and Allergy Clinic, 36 patients, who according to earlier
examinations fulfilled the criteria of SNAR were invited. The criteria were symptoms of
rhinitis during the pollen season (April - August) at least one of the last two years and
negative SPT with a standard allergen panel consisting of standardized extracts of pollen
(birch, timothy and mugwort), dog, cat and horse epithelium/dander, Dermatophagoides
pteronyssinus and unstandardized extracts of Cladosporium and Chironomid (red mosquito
larvae) (NE Eriksson et al
1989) . Seventeen patients
accepted to take part in the study (Table 1). One of the patients moved from Halmstad
after having been included in the study and could not come for in vivo- or in
vitro-testing.
SAR group
The SAR
group was matched with the SNAR group according to age and sex. All had positive (>2+)
SPT results with birch and/or timothy pollen extract, performed during one of the three
latest years, and suffered from seasonal rhino-conjunctivitis during the pollen
season at least one of the two latest years. Two patients, who earlier had been classified
as SNAR, had later developed a pollen allergy with positive SPT to birch pollen and were
therefore included in the SAR group. Of 36 patients selected, 20 individuals accepted to
take part in the study (Table 1).
PNAR group
The PNAR group consisted of patients having perennial rhinitis symptoms and
negative SPT results with the standard allergen panel. Two patients, who earlier had been
regarded to have SNAR, were found to have only perennial symptoms according to the present
history and were therefore included in the PNAR group. Of the 16 invited individuals, 13
accepted to take part in the study (Table 1).
The
patients symptom/case history
was obtained via a questionnaire, in which we asked for type of symptoms, duration, season
and eliciting factors (like birch twigs, strong smells, birch pollen related foods). The
patients were asked to grade their symptoms according to the following scale: 0 = no
symptoms, 1 = mild symptoms, 2 = moderate symptoms, 3 = severe symptoms, regarding the
following symptoms during spring and summer: blocking, running, sneezing, impaired sense
of smell, itching of the eyes, breathlessness. Furthermore, their symptoms were recorded
on a visual analogue scale (1 = no or very slight symptoms, 10 = very severe symptoms).
SPT was
performed before the pollen season in accordance with the routines at the clinic (NE
Eriksson et al 1996) and in accordance with
consensus documents (S Dreborg 1989) . The
following Soluprick 10 HEP pollen allergens (ALK-Abello, Hørsholm, Denmark) were used:
birch, alder, hazel, elm, oak and six different grasses (timothy, meadow foxtail,
cocksfoot, oat grass, meadow fescue and rye) and mugwort. The wheals were measured after
10-15 minutes and recorded in accordance with Nordic guidelines (K Aas et al 1973)
.
Thus, a wheal reaction of the same size as that of a positive histamine reference
(histamine HCl 10g/l) was recorded as three plus (3+) and a wheal half the size of the
positive control was recorded as 2+. Reactions >2+ were regarded as
positive. No oral antihistamines were allowed
five days before the testing. The patients were asked to report if late SPT reactions
occurred after 4 h, 8 h or the following morning.
The provocations were performed as follows: With a Carlsberg pipette 25 µl
control solution was delivered on the inferior turbinate in the nasal cavity on each side.
If there were no local symptoms the provocation was proceeded with application of 25 µl
allergen extract (Aquagen, birch or timothy pollen, ALK-Abello) on the inferior turbinate
in each nasal cavity. With 10 minutes intervals, allergen extracts of stepwise increasing
concentration (100, 1000, 10.000 and 100.000 SQ-units/ml) was administered bilateral in
the nasal cavity. During the challenge procedure symptoms of sneezing, running nose, nose
block, itching and respiratory symptoms were continuously measured on a symptom chart
using a 4-point scale (0 = no, 1 = mild, 2 = moderate, 3 = severe symptoms). If the
calculated sum of the scores for each symptom exceeded 3 the provocation was considered
positive and further provocation was omitted. If the test subject was free from symptoms
after provocation with the allergen extract of the highest concentration, a further
provocation was made with pure pollen grains from birch or grass. Late symptoms were
registered at home during the next 24 hours by the test subjects using the same symptom
score and chart as above.
During the
challenge procedure acoustic rhinometry was used to evaluate the reaction of the nasal
mucosa (M Ganslmayer et al
1999; H Lenders et al 1990) , Mean value of the area
in the valve plane (cm2) and mean value of the volume in the anterior nasal
segment (cm3) was measured before testing and after each provocation.
All the patients recorded symptoms (eye symptoms, blocking, itching and running
nose, sneezing, and coughing) according to a 4-grade scale (0 = no symptoms, 1 = slight
symptoms, 2 = moderate symptoms, 3 = severe symptoms) as well as the consumption of
antihistamine tablets, local antihistamines for eyes or nose and nasal steroids. The
number of tablets, doses of inhalations or number of eyedroppers were recorded: 1 tablet,
1 dose etc = 1 score, 2 tablets, 2 doses etc = 2 score etc. The mean score per week was
calculated.
If the patient had an infection or did not stay in the hometown it was recorded
in the protocol. The patient protocols were mailed to us every second week. The recordings
were performed from March 6 to July 30, 1995.
The presence of IgE antibodies in patients´ sera to common inhalant allergens
was investigated using Phadiatop® (Pharmacia Diagnostics AB, Uppsala, Sweden).
The concentrations of total and specific IgE antibodies were analyzed using Pharmacia CAP
SystemTM (Pharmacia Diagnostics AB). Specific IgE antibodies were measured
against grass pollen (timothy) and various tree pollen (gray alder, common silver birch,
hazel and mountain juniper). The cut-off value of the specific IgE assay was 0.35 kUA/l.
The concentrations of tryptase, ECP and MPO were determined in nasal lavage
collected before and after NPT. The immunoassays used were UniCAP Tryptase, UniCAP ECP and
Pharmacia MPO RIA (all from Pharmacia Diagnostics AB). The nasal lavage samples were
diluted 1:2 in sample diluent prior to analyses according to the recommendation of the
manufacturer (personal communication). The cut-off values of the immunoassays were 1 ng/ml
(tryptase), 2 ng/ml (ECP) and 8 ng/ml (MPO).
The number
of pollen in the air were recorded in Halmstad using a Burkard’s Volumetric Spore
Trap placed on the roof of a building at Halmstad hospital. The pollen tapes were sent
five days a week to the Botanical Institution at University of Gothenburg for analyses
(M
Käpylä et al 1981) .
For comparisons of clinical data between the groups ?2 test was used.
To identify significant differences in concentrations of serum IgE antibodies, and
tryptase, ECP and MPO in nasal lavage samples, the Wilcoxon-signed ranks test and
Mann-Whitney U-test (two tailed P-value) were used for within group and between group
comparisons, respectively. P values <0.05 were regarded as significant.
The study was approved by the Ethic Committee of University of Lund.
The majority of the patients in the SNAR group (12/16) had rhinitis or
rhino-conjunctivitis only during spring or spring and summer whereas all the patients in
the PNAR group had perennial symptoms (P<0.001). Of the patients in the SNAR group,
3/16 had symptoms in spring and autumn and 1/16 in summer and autumn. In the SAR group
9/19 had symptoms only at springtime, 6/19 in springtime and summertime and 2/19 in
summertime. Two patients had symptoms also out of the pollen season. There was no
significant difference between the SAR and SNAR group regarding symptoms season according
to the questionnaire. The SAR group had more severe eye symptoms than the SNAR and PNAR
groups (P<0.01), but there was no significant difference between the groups regarding
other symptoms. Patients in the SNAR group complained of symptoms induced by flowers
(P<0.05) and birch twigs (P<0.01) more often than the PNAR group (Table 2). There
was no significant difference between SNAR and SAR regarding symptoms from flowers and
birch twigs. Nuts and fresh fruits more often induced allergic symptoms in SAR than SNAR
and more often in SNAR than in PNAR group. However, it was statistically significant only
between the SAR and PNAR groups (Table 2). There was no significant difference between the
groups regarding symptoms induced by tobacco smoke, perfumes, car exhaust, printing ink,
weather and foods other than nuts and fresh fruits.
Hypersensitivity against acetyl salicylic acid (ASA) was reported by 3/15 of the
SNAR patients, 2/19 of the SAR and 1/13 of the PNAR patients.
All the SAR patients had positive immediate type reaction at SPT with birch
pollen or timothy pollen whereas the SNAR and the PNAR group had negative immediate skin
tests with all the allergens used (Table 3). It should be noticed that two patients, who
according to earlier test results were regarded as SNAR, later on had developed positive
SPT with pollen and now were included in the SAR group. Late SPT reactions occurred in two
SNAR patients and two PNAR patients (Table 3).
NPT with pollen allergens was performed on 15 SNAR patients, 19 SAR patients and
13 PNAR patients. All individuals in the SAR group had positive NPT. Three of 15 patients
in the SNAR group and 1/13 in the PNAR group had a positive immediate type NPT with birch
pollen in spite of a negative SPT. Only in one of these cases allergen in solution (100
000 SQ units/ml) induced symptoms whereas the other cases only got symptoms on provocation
with pollen grain. Of the patients in the SNAR group 7/15 reported a late reaction after
the provocation. Among these were the three individuals who had a positive immediate
reaction. Of the patients in the PNAR group 5/13 reported late reaction. Included in this
group was the patient who had a positive immediate reaction and the two persons who
earlier had been regarded as SNAR patients but in this study were included in the PNAR
group due to their present case history (Table 4).
The curves from the rhinometry recordings did not show any changes with
increasing allergen concentration in the SNAR and PNAR groups, whereas the SAR group
showed signs of increasing mucosal oedema with increasing allergen concentration (Fig. 1).
The patients in the SNAR and PNAR groups had symptoms already at the start of the
recordings (March 6, 1995) and their symptoms gradually decreased during the period. The
SAR group had only slight symptoms at the start of the recordings and very much increased
symptom scores during the pollen season. The consumption of medicine was high at the start
in the SNAR group and was gradually decreasing during the pollen season. In the PNAR group
medicine consumption was low initially and slowly increased during the observation period.
The SAR group showed an obvious increase in medicine consumption week number 19, after the
peak of the birch pollen season.
The pollen recordings showed that the maximum count for birch pollen occurred
week number 17 and for grass pollen week number 26. Figure 2 shows the mean weekly symptom
and medication score in the three patients groups as well as the pollen counts.
The most common symptoms recorded during the pollen season were in the SNAR group
sneezing. In the SAR group the main symptoms were sneezing and less often eye symptoms,
blocking nose and running nose. In the PNAR group blocking nose was most common, followed
by sneezing and running nose.
Analyses of total and specific serum IgE antibodies were performed in 15 patients
in the SNAR group, 15 patients in the SAR group and 11 patients in the PNAR group. The
total IgE levels were significantly lower in the SNAR group (13.5 [2.4 - 459] kU/l, median
with range) compared to the SAR group (33.2 [9.1 - 200.3] kU/l, P<0.05). No significant
differences in total IgE between the PNAR group (41.1 [2.0 - 187.5] kU/l) and the SNAR or
SAR groups were noted.
In the SNAR group 1/14 patients were positive in Phadiatop, an indication of
circulating IgE antibodies against inhalant allergens. All 16 patients tested in the SAR
group were positive in Phadiatop, while all 11 patients analyzed in the PNAR group were
negative. Specific IgE antibody measurements revealed that all patients in the SNAR group,
including the Phadiatop-positive patient, were lacking serum IgE antibodies against all
tree and grass pollen allergens tested. All patients in the SAR group had circulating IgE
antibodies against one or more of the pollen allergens tested (frequencies of IgE
reactivity: timothy, 50%; grey alder, 75%; common silver birch, 81%; hazel, 69%; mountain
juniper, 0%). None of the patients in the PNAR group had IgE antibodies to the pollen
allergens tested.
The concentrations of tryptase, ECP and MPO were determined in nasal lavage
samples collected from 15 patients in the SNAR group, 19 patients in the SAR group and 11
patients in the PNAR group. The concentrations were below the cut-off values of the
immunoassays for most of the patients. No significant differences between the study groups
were observed. Neither were any significant differences observed within the SNAR and PNAR
groups between nasal lavage samples collected before and after NPT. It was, however,
significant increased tryptase levels in the SAR group after NPT (11.0 ± 33.8 ng/ml, mean
± SD) compared to before NPT (1.4 ± 1.6 ng/ml, P<0.05). Six of 19 patients in the SAR
group and none in the SNAR and PNAR groups showed increased tryptase levels in nasal
lavage after NPT (Fig. 3A). Furthermore, there was a trend towards increased ECP levels in
nasal lavage after NPT in the SAR group (Fig. 3B). No significant changes or trends were
observed for MPO in nasal lavage (data not shown).
In the present study a group of patients with seasonal rhino-conjunctivitis and
negative SPT (SNAR group) were compared with a group of hay fever patients (SAR) and a
group of patients with persistent non-allergic rhinitis (PNAR). SPT with 12 different
pollen allergens, recorded after 10-15 minutes, as in routine diagnostic work, was
negative in the SNAR group. Late reactions were, however, reported by two patients. NPT
with birch pollen was positive in three patients of the SNAR group. Furthermore, seven
patients reported a late nasal reaction. The symptom and medication score during pollen
season did not increase in the SNAR group; they rather had high scores before the pollen
season and their score gradually decreased.
Patients in
the SNAR group had significantly lower total IgE levels than the patients in the SAR
group. It does not exclude an IgE-mediated mechanism, however, since total IgE is a rather
unspecific marker for allergic symptoms (JH Droste et al 1996)
.
Allergen-specific IgE antibodies are more sensitive and specific markers for seasonal
pollen allergy (JH
Droste et al 1996) .
By using the Phadiatop
test, circulating serum IgE antibodies specific for common inhalant allergens can be
detected (NE Eriksson 1990)
. In
our study, one of the patients with the diagnosis of SNAR was positive in Phadiatop but we
could not find any IgE antibodies to the pollen allergens tested. This may indicate an
allergy to perennial allergens rather than to seasonal pollen allergens.
The
syndrome SNAR has earlier been described in a study where patient data were
retrospectively analyzed (NE Eriksson 1991)
.
That study indicated that SNAR patients compared to birch pollen allergics had symptoms
earlier in springtime than pollen allergics and more often got symptoms from flowers and
strong smells. The age of the SNAR patients was higher than the age of the birch pollen
allergic patients and there were more women in the SNAR group than in the group of pollen
allergics. It was concluded that SNAR seemed to have more in common with PNAR than with
seasonal allergic rhinitis.
Our SNAR patients have, according to their histories, seasonal symptoms. It is
probable that in the present study the registration of symptoms started to late to catch
the start of the symptom season.
Our present
study cannot explain the cause of the symptoms of SNAR. One possible explanation could be
unspecifically acting substances in pollen grains eliciting symptoms. Another explanation
could be a pollen allergy, not discovered in routine SPT. The finding of one
Phadiatop-positive patient in the SNAR group indicate that an underlying respiratory
allergy could be the reason for the symptoms for that particular patient diagnosed only by
case history and SPT. For diagnosis of a clinically relevant allergy, a combination of the
information obtained from history, skin tests and specific IgE tests is the most sensitive
method (NE Eriksson 1977)
. The
positive NPT with pollen in some of the SNAR patients, as well as some late reactions
after NPT, could indicate a pollen allergy. Also the fact that two patients who earlier
had been regarded as SNAR patients were found to be SPT positive when tested at the start
of the study (they also had specific IgE antibodies to pollen allergens), could indicate a
connection between SNAR and birch or grass pollen allergy. Another possibility could be
chemical pollutions bounded to pollen grains inducing symptoms (C Traidl-Hoffmann et al
2003) . The symptom score
curves, however, do not support a reaction related to tree or grass pollen, since the
patients in the SNAR group had symptoms already before the pollen season and their
symptoms gradually decreased during the registration period. Their symptoms did not
increase during a period with high pollen counts. Furthermore, in only the SAR group did
nasal provocation with pollen allergens induce mucosal oedema and a significant increase
in the nasal lavage levels of tryptase, a sign of mast cell degranulation. We also
observed a trend towards increased ECP levels in the nasal lavage samples of the SAR
patients. The increase in ECP might have been more apparent if the nasal lavage fluid
sampling after NPT had been performed later, i.e. during the late phase response as shown
by others (A van Toorenenbergen et
al 1992) .
An allergy
with sensitization against allergens not included in the present study is of course
possible, although pollen recordings do not indicate that other pollens occur in early
spring-time (SO Strandhede et al
1984) , nor do allergenic
moulds occur during this period in Sweden. Furthermore, clinically significant allergy
against other tree pollen is very seldom found in Sweden (NE Eriksson et al
1984) . An allergy not
possible to demonstrate with present diagnostic methods is another possibility. In routine
diagnostic work using SPT, late skin test reactions are usually not recorded. Two of our
SNAR-patients reported positive late skin reaction. It is not clear whether such reactions
have clinical significance (MB Lierl 2000) .
We cannot
either exclude that the symptoms of the SNAR patients are caused by unknown substances in
the outdoor or indoor air in springtime. MPO is a marker for neutrophilic activity even if
also monocytes can synthesize lower amounts of MPO. Increased MPO concentrations in nasal
lavage have been shown to be associated with exposure to non-specific irritants (M Ahman et
al 2001) or upper respiratory
tract infections (C Bachert et al 2001)
. We
did not observe any elevated MPO levels in the SNAR group, neither in the SAR and PNAR
groups. So involvement of neutrophils in the manifestation of SNAR could not be
demonstrated.
To conclude, patients with seasonal rhinitis occur with negative results of
allergy testings. The present study indicates that these patients have a disease different
from seasonal allergic rhinitis (SAR) and persistent non-allergic rhinitis (PNAR)
regarding immunological mechanism and symptom period. We call this syndrome seasonal
non-allergic rhinitis (SNAR). Still, we cannot exclude that some of the SNAR patients
might have a pollen allergy, not disclosed by standard skin prick tests. For most of the
SNAR patients, however, the reason for their symptoms is unknown. It may be an unspecific
hypersensitivity against substances occurring in outdoor or indoor air in springtime.
We thank Dr Lena Elfman at Pharmacia Diagnostics for valuable suggestions about
in-vitro tests for this study. Halmstad county hospital supported the study.
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Nils E Eriksson
Gaggegatan 17b
SE-30237 Halmstad
E-mail:[email protected]
Telephone: +46-35 129150
Fax: +46-35 130397
Table 1. Patients and inclusion criteria
* Positive (>2+) for birch and/or timothy pollen
Table 2. Factors eliciting symptom according to patients´ answers to a
questionnaire
Table 3 Results of skin prick tests (SPT)
Immediate reactions were recorded after 10-15 minutes.
Late reactions were recorded by the patients after 4h, 8h or the following
morning
Table 4. Results of nasal provocation tests with birch and/or timothy pollen
* Missing data regarding late reactions for one patient
Seasonal Non-allergic rhinitis (SNAR) – A new disease entity? A clinical and
immunological comparison between SNAR, seasonal allergic rhinitis and persistent
non-allergic rhinitis.
Figure 1
Rhinometry after provocation with birch or grass pollen in the three patient
groups. The mean values of the volume (cm3) in the anterior nasal segment are
shown.
Figures 2
Pollen counts and symptom and medication score before and during the birch and
grass pollen season. Weakly means, calculated from patients´ daily recordings.
Figure 3
Concentrations of tryptase (A) and ECP (B) in nasal lavage samples from patients
in the SNAR, SAR and PNAR groups before and after nasal provocation with birch or timothy
pollen allergens.