CASE REPORT

ALLERGIC RHINITIS

INTRODUCTION
Allergic rhinitis is one of the common immunological diseases. Based on epidemiological study, the prevalence of allergic rhinitis is about 1020% and constantly increased in the last decade

Allergic rhinitis based on WHO ARIA (Allergic Rhinitis and its Impact on Asthma) defined as nose problems with symptoms such as sneezing, a lot of serous rhinorrhea, and also itch and obstruct sensation in nose after the nose mucosa exposed by allergen IgE.

Anatomy
External nose consist of 2 part -1/3 made of bone -2/3 made of cartilage External nose shaped like pyramid, consist of few structure like -root apex (dorsum nasi) -nares (nostrils) alae (lateral boundary) kolumela (septum) (K.L Moore 5th ed)

Cavum nasi shaped like tunnel,consist of - nares anterior to nares posterior (choana) - septum nasi - vestibulum (contain sebaceous gland and vibrisea) - nasal fossae (chonchae inferior, media, superior) (K.L Moore 5th ed)

Histology
The wall of cavum nasi layered by tunica mucosa. Based on the histologic and functional feature of the mucosa,they are divided into -respiratory mocosal -olfactory mucosal

Respiratory mucosal - cilliated pseudostratified collumner epithelium) -Goblet cells Olfactory mucosal - layered the conchae superior,1/3 upper part of septum -pseudostratified columner non cilliated epithelium - contain 3 type of cells *olfactory receptor cells, sustencular cells, basal cells
(Wheathers Functional Histology,5th ed)

Physiology
respiratory function - balanced the humidity and temperature of the air before entering the body Protection -vibrisae,silia,mucous blanket filter the dust particle, microorganism Sensory organ -contain olfactorius mucosa Phonation - resonator

Allergic rhinitis
Definition
Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose
(ARIA, 2008)

Classification Based on seasonality Seasonal allergic rhinitis: triggered by seasonal increases in relevant antigens (pollens and outdoor molds) Perennial allergic rhinitis: occurring throughout most of the year, and related to perennial antigens (animal dander, dust mites, cockroach, and indoor molds)

Classification
Intermittent
< 4 days per week or < 4 weeks

Persistent
4 days per week and 4 weeks

Mild
normal sleep no impairment of daily activities, sport, leisure normal work and school no troublesome symptoms

Moderate-severe
one or more items abnormal sleep impairment of daily activities, sport, leisure abnormal work and school troublesome symptoms

Etiology allergic rhinitis

Pathophysiology -Immediate phase allergic reaction (from exposure to 1 hour) -Late phase allergic reaction (occur 2-4 hours up to 24-48 hour)

A: Early response: In the early response to nasal allergen challenge, mast cell activation causes symptoms secondary to mediator release. B: Late response: In the late response to allergen challenge, cell recruitment via cytokines causes the accumulation of multiple inflammatory cells in the mucosa, which in turn release mediators that lead to symptoms, hyperresponsiveness to irritants, and priming (increased responsiveness to antigen).

Clinical Manifestations
Classic symptoms

Sneezing Itching Rhinorrhea Nasal congestion

CASE REPORT
A. ANAMNESIS Patients Identity: Name: Mr. RS Age: 36 years old Gender: male Occupation: trader RM : 00.22 24 55 Main complain: Recurrent cold

History of present illness:

Patient came to THT policlinic on 29th September 2011 with the main complaint of recurrent cold which he suffered for the past 6 years. The complaint had worsen during this 2 month. The patient always sneezes and his nose feel stuffy and watery when exposed to dust. His eyes were itchy, watery and red. The symptoms are worsening in the morning and when he feels cold

Past medical history: The complaint has persist for the past 6 years, the patient only seek for medical help when he feel that those symptoms affect his work. The patient never did any allergic test before. He claimed that he had taken over the counter medication but still no improvement. History of asthma (-), heart disease (-) or diabetes mellitus (-).

Family history: No family members experienced same symptoms as his

B. Physical Examination

General conditions: CM, well nourished Vital sign: Blood pressure: 110/80 mmHg RR: 20 bpm Temp: 36.7 0C

ENT Examination Ear examination: normal range Throat examination: normal range Nose examination: nasal mucous membrane and conchae appears hyperemic, edema and livid. Discharge was (+) serous and clear. Allergic Shiners (+)

Supporting examination:

Skin prick test Tested positive to house dust, particle of human skin, particle of dog skin, particle of horse skin, tepung sari padi (pollen), tepung sari jagung, cashew nuts, chocolate, egg and tea.

Diagnosis
Allergic rhinitis persistent moderate severe

Treatment
Cetirizine (10mg) 1x1 Phadilon (4mg) 2x2

Planning
Symptomatic therapy Avoid or minimized the exposure to the allergen (clean the house regularly or face mask)

G. Education Take medication as instructed Come to the clinic again when he finished his medication or when his symptoms worsen. Avoid or minimized the exposure to the allergen by using face mask Practice healthy lifestyle like exercise 20min/day, take enough nutrition, have proper rest

DISCUSSION
Allergic rhinitis is one of most common atopic disease in this few decade. Predisposing factors: genetic, environment, infection Transmission inhaled, ingested, direct contact to skin Bailey (2006)

This disease involve the immune reaction where there is an imflamatory reaction occur in the mucosal of cavum nasi. Sign and symptom: nasal congestion, sneezing, itchy nose and eyes, rhinorea Clinical finding: mucosa and conchea livid or pale, serous and clear secrete, post nasal drip,allergic shiner,allergic crease, and allergic salute sign. ARIA 2008

Simple test that can be done to confirm the alergic rhinitis is allergic test ( skin prick and puncture test) (Adkinson 2008) The patient in this case are tested positive for few allergen substance in the test.

After the comfirmation of rhinitis alergy, we classify this patient based on the classification of ARIA 2008, which in this case persistent moderate severe. We educate the patient about the disease and give treatment according to PERHATI KL antihistamine , corticosteroid and decongestan

Problem: recurrency Because the allergen is house dust which is hard to avoid. We educate the patient on how to minimize the exsposure to the dust by cleaning the house regularly and wear mask.

CONCLUSION
There is a male patient, 36 years old diagnosed as allergic rhinitis moderate severe persistent. To this patient, we already educate him about the disease, we prescribed antihistamin Cetirizine (10mg) 1x1 and methyl prednisolon Phadilon (4mg) 2x2. We have advised him to come again to the THT policlinic to re evaluate the effect of the medication given to him in 2 weeks.

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