Allergic Rhinitis - Journal International de Santé au Travail

Allergic Rhinitis: epidemiological, clinical and treatment aspects in General
Hospital of Douala.
Rhinite allergique: aspects épidémiologiques, cliniques et thérapeutiques à
l'Hôpital général de Douala.
Francis Nde Djiele1,2, Hugo Bertrand Mbatchou Ngahane1, Vincent Fonyam3, Amadou Njifou Njimah4,
Audrey Esse3, Richard Njock1,3.
1. Faculty of Medicine and Pharmaceutical Sciences at University of Douala
2. School of public Health of Université libre de Bruxelles
2. Douala General Hospital
3. Mbouda Hospital
Correspondent author: Francis Nde1: [email protected]
Summary
Objective. The objective of this study was to describe the epidemiological , clinical and therapeutic patterns of
allergic rhinitis in Douala General Hospital (DGH)
Method. We conducted a descriptive, retrospective and prospective study of 528 patients in the ENT department
of DGH from November 1st 2012 to May 31st 2013 . The prick tests profile was determined only on the
prospective part, 86 patients. Data were processed with SPSS Version 20 software.
Result. The sex ratio female / male was 0.71. The average age was 24 years, 40% were students and 95 % of the
sample lived in urban areas. Clinical manifestations, sneezing represented 83.5%, nasal obstruction 79.2%, clear
rhinorrhea 75.4%, and pruritus ENT 68.9 % of cases. Allergens found were 30.6% mites , mold and cockroaches
26.4% to 15%. Allergic rhinitis was associated with asthma in 3% of cases and sinusitis in 3% also. The
antihistamine and corticosteroid combination was preferred in 72 % of cases.
Conclusion. Allergic rhinitis is relatively common in ENT consultation of HGD . The main symptoms observed
are sneezing , nasal obstruction, rhinorrhea clear and pruritus ENT . The epidemiological and clinical profile
should allow a better approach to patients presenting with allergic rhinitis medical consultation in Douala. J Int
Sante Trav 2014;1:12-24
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Allergic Rhinitis
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Résumé
Objectif. L’objectif de cette étude était de décrire les aspects épidémiologiques, cliniques et
thérapeutiques de la RA et d’en déterminer le profil de sensibilisation aux allergènes à Douala.
Méthode. Nous avons mené une étude descriptive, rétrospective et prospective sur 528 patients dans le
service ORL de l’HGD du 1er Novembre 2012 au 31 Mai 2013. Le profil de sensibilisation n’a été
effectué que sur la partie prospective, soit 86 patients. Les données ont été traitées avec le logiciel IBM
SPSS version 20.
Résultat. Le sexe ratio femme/homme était de 0,71. L’âge moyen était de 24 ans, 40 % étaient des élèves,
et 95% de l’échantillon habitaient des zones urbaines. Des manifestations cliniques, l’éternuement
représentait 83,5%, l’obstruction nasale 79,2%, la rhinorrhée claire 75,4% et le prurit ORL 68,9% des cas.
Des allergènes retrouvés étaient les acariens 30,6%, les moisissures 26,4% et les blattes 15%. La rhinite
allergique était associée à l’asthme dans 3% des cas et à la sinusite dans 3% également. L’association
antihistaminiques et corticoïdes était préféré dans 72% des cas.
Conclusion. La rhinite allergique est relativement fréquente en consultation ORL de l’HGD. Les
principaux symptômes observés sont l’éternuement, l’obstruction nasale, la rhinorrhée claire et le prurit
ORL. Ce profil épidémiologique et clinique devrait permettre une meilleure approche des patients se
présentant avec rhinite allergique en consultation médicale à Douala.
Key words: Allergic rhinitis, asthma, sensitization, Africa.
Mots clé : Rhinite allergique, asthme, sensibilisation, Afrique.
Introduction
Allergic rhinitis (AR) corresponds to the set of functional events generated by development of a nasal
immunoglobulin E (IgE) dependent inflammation in response to exposure to various types of allergen. 1 It
is characterized by one or more of symptoms such as sneezing, itching of the ear, nose and throat (ENT)
area, runny nose and nasal obstruction.2
Recent epidemiological studies have confirmed that this is a public health problem which mainly face
GPs, ENT specialists, pediatricians, pulmonologists and allergists and occupational physicians for
professional AR. Many authors report that AR is increasing. 3
It affects more than 600 million people worldwide, with a prevalence of 10 to 40% of the general
population according to studies. 4 In 2006 in France, population affected by respiratory allergy in general
was estimated at 20 to 25% versus 3.8% in 19685.
Its incidence has been multiplied by four in 30 years. 6
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AR is a very common condition , especially in children in whom, the condition is under diagnosed and
under treated7,2, especially because of frequent self-medication and lack of access to a physician and poor
attention to the disease. Although it is not a severe disease in itself, allergic rhinitis is often associated
with other airway diseases, including asthma, sinusitis, otitis media and nasal polyposis 8 which see their
prognosis, management and cost modified by the presence of AR.
Therefore, AR can affect not only the quality of life of patients, with changes in sleep, social life, school
and work performance9,10, but also on the socio-economic life with substantial direct and indirect costs 11.
The direct costs are incurred directly by the disease that is the cost of consultations and treatment, and
indirect costs associated with comorbidities and the impact of AR on productivity for workers.
In 1999, the World Health Organization (WHO) convened a group of international experts who drafted a
consensus called ARIA (Allergic rhinitis and its impact on asthma) to bring up-to-date on AR and
establish an adequate therapeutic approach. 1,10
If the data on the epidemiological and clinical patterns, and therapeutic practices of AR seem to be well
established in other places, the fact remains that in some countries such as Cameroon, some deficiency
are observed. In addition, the climatic conditions of our country, and especially those of the Littoral
Region, suggests that environmental allergic factors may develop.
The equatorial climate is hot and humid 12 six months of the year, and seems to favor a strong growth of
mold and mites that can be an aggravating factor of this disease. It is therefore important to make the
point regarding this disease in our community.
That is why we proposed to conduct this study whose aim was to study the epidemiology, clinical
presentation and treatment of patients with allergic rhinitis, and determine the profile of allergen
sensitization.
Material and methods
This study took place in the ENT department of the Douala General Hospital. This hospital facility is
located in the Littoral region, the economic capital of Cameroon.
We made a retrospective review of file of patients with AR diagnosed from 1 January 2007 to 30
December 2012. We entered data in IBM SPSS statistics 20, which allowed us to carry out descriptive
statistics and derive proportions which were then represented in figures drawn from excels.
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Results
The average age of our patients was 24 years (min=1 and max=87) (n=528).
Ninety four percent (94 %) were lived in urban areas and 5 % in rural zones (n=497).
We found the triade sneezing, nasal obstruction and rhinorrhoea in 53.6 % of cases (n=528)
Figure 1 Symptoms found in AR in our sample.
The most common symptoms were sneezing, nasal congestion, clear rhinorrhea and ENT pruritus.
Figure 2 triggering factors of AR in our sample.
The most common triggering factors of AR were dust and cold.
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Figure 3 Clinical pattern of AR found in our sample.
Clinical patterns were essentially pale mucosa, followed by hyperthrophic inferior burbinate and inflamed
mucosa.
Figure 4 ARIA classification of our sample.
The classification of our sample following ARIA showed that moderate-severe were the most represented,
followed by Intermittent. Mild and persistent were less frequent.
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Figure 5 ARIA classification by gender in our sample
The two most common forms are found in women with a higher frequency that in men who had manly
mild and persistent forms.
Figure 6 Sensitization pattern.
The two main allergens found were Der f and Der p in our sample. Cockroaches and aspergillus were
following but with lower frequency.
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Figure 7 Distribution of patients according to treatment modalities.
The preferred treatment was general anti H1 and intranasal corticosteroids. The rest were very marginally
used by prescribers.
Discussion
Epidemiological pattern
Gender
We found female/male sex ratio on 1.4, which goes with what Nyembue et al. in Congo 13 and a French
survey.14 This female predominance seems to be explained by hormones. 15 Other authors use the
hypothesis of stressful situation to occurrence of allergic rhinoconjonctivitis. 16.
Age
Average of age in our sample was close to the one found in Nyembue et al. 13 and Ciprandi et al. 17 studies.
Few studies showed that adolescents were the most affected by the condition, but there are so far no
physiological explanation about the most affected age group. 18.
Profession
Schoolchildren and student were most represented in our series. AR is a debilitating condition resulting in
a deterioration of the quality of life of patients and especially young people. 15,16 The symptoms have an
impact on their learning, memory, concentration and wellbeing. 9,11,16 That could lead to frequent drug
intake in this vulnerable age group.
Place of origin
Most of our patients were from urban areas. Nyembue et al. 13 found a similar tendency in Congo. This
could be explained by industrial pollution in cities as suggested by Gaetan et al. 16
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Indeed, the pollution would have a pro-inflammatory effect on the nasal and bronchial mucosa, increasing
the infiltration of allergens in the airways as well as majoring nasal and bronchial hyper reactivity in
atopic subjects.19
Besides that, we may highlight the state of the domestic and office environments which are subject to
inadequate ventilation and moisture thus promoting the development of sensitization to dust mites and
mold.
Clinical pattern
Clinical presentation
Majority of our patient presented with the triad of AR as announced in the ARIA recommendations1.
Sneezing, nasal obstruction and clear rhinorrhea and ENT pruritus where found prevalent in our sample
like in Didier et al [20].
These symptoms are secondary to a nasal hyper activity in response to an exposure to stimuli. We found
few cases of headache in our study, which could be related to sleep disorder common in AR. 9,11 or by
increased intracranial pressure resulting from repeated sneezing and coughing.
ARIA Classification
To classify patients according to ARIA , we took into account the duration and severity of the symptoms
that patients reported to the interrogation. They complained of discomfort in daily activities or sleep
disorders . In our series, based on symptoms reported by patients, persistent moderate to severe AR is the
most common presentation.
Data from the literature are disparate regarding the ARIA classification and values differ from one study
to another. Our results are close to MARIA et al. 21 in Italy. This is explained by patient carelessness about
their symptoms and therefore they only consult, only at later stages, when they experience symptoms such
as sleep disorders or lack of concentration.
Our findings about intermediate stages was similar to those of Antonicelli et al. 22. Finally, we found that
women were more represented in late stages than men, the only hypothesis so far found being hormonal
presence.
Physical signs
The physical examination of the patient with RA is not specific and often normal but literature reports
pale mucosa that could be observed and an inferior turbinate hypertrophy when the patient is in crisis
[1,10,16]. In our study, the majority of patients were rather normal on examinations. Only few had a
turbinate hypertrophy or pale mucosa. Very few data in the literature concerning the frequency of polyps
in patients with AR. In our study, we found nearly no case of polyps, like in Schoenwetter et al. Series. 23
Comorbidities
Epidemiological studies show that AR is rarely isolated as allergic inflammation is not limited to the nasal
mucosa but spreads to the bronchial mucosa1,16. It is frequently associated with asthma at different rates
according to authors. In our study we found a far lower rate for the co-existence between these two
diseases, as compared to Schoenwetter et al. 23 and Bousquet et al.4
The co- existence of these two conditions is indeed a highlight of ARIA consensus which shows the
benefits of routine screening for these two conditions. Demoly et al. 22 explain the co-existence of these
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two conditions by the co-inflammation of both nasal mucosa and bronchi. Our poor rate is likely due to
lack of asthma investigation in our consultation.
We found lower association between AR and sinusitis than in the literature in similar setting. 25,26 In our
series again, we believe that could be due to poor diagnosis of sinusitis or simply lack of its research.
Triggering factors
Several studies identify specific allergens and house dust as triggers of AR crisis. 1,7,8 In our series, nearly
half of cases were caused by house dust. In Tanzania Said et al. 27 evoked strong smells of perfume and
cold temperatures without specifying specific rates for each factor.
In this work, we had a fifth of cases due to cold environments and less than a tenth to strong odor of
perfume. A poor hygiene in homes, and alternate hot and cold variations in Douala could explain these
trends. But also the misuse of fans and air conditioners, lack of maintenance favor excessive deposition of
dust which is then released into the atmosphere, causing nasal hyper reactivity.
Allergens sensitization pattern
More than two third of our prick tests were positive which goes These trends are similar to those of
Ngom et al.28 and cisse et al.29 in Côte d'Ivoire and Aydin et al. 30 in a completely different setting in a
Turkish study. In our settings, culturally, domestic animals are not that present in houses.
That may explain the low number of cases caused by animals. Mites occupied concordantly a prominent
place in the distribution of allergens identified in the majority of studies, probably due to their ubiquitous
nature in common used materials like bedrooms mattresses, sheets, carpet, which are their preferred
ecological niche, where human skin at favorable temperature and humidity represent their food source.
Similar observation could be made of molds represented as the second largest allergens identified in our
series, as Bakonde et al.31
They are also common in domestic environments as dust mites and they thrive in similar conditions of
moisture, heat and lack of ventilation frequent in our environment. Cockroaches were also represented,
though less than literature32,33, showing a certain poor hygiene and precarious setting.
Polysentitization found in our study, higher than literature could be explained by multiplicity of allergens
due to excessive dispersion of pollutants in our environment.
Therapeutic pattern
The therapeutic strategy established by consensus ARIA recommends treatment depending on the stage of
AR. In our series, all patients had received medical treatment and the most prescribed molecules were
antihistamines and intranasal corticosteroids. Maios et al. 34 made the same observation in their series. in
more than two third of cases in our study, we found an association of antihistamines and intranasal
corticosteroids.
Yet the consensus ARIA recommends this association in forms of persistent moderate to severe AR. Our
therapeutic practices are not in line with those recommended by the consensus ARIA.
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Conclusion
We conclude that AR is a disease that mostly affects young people with a female preponderance.
Schoolchildren and students are the most affected. Its diagnosis is mainly based on a thorough history and
physical examination.
The practice of skin prick tests is not a diagnostic aid but identifies the major allergens involved in the
onset of clinical manifestations of AR in our midst.
Of the 12 varieties of allergen extracts that we tested, it emerged predominantly dust mites, mold and
cockroaches.
Asthma is associated so tiny in AR unlike other authors who found in 30% on average. Antihistamines
and nasal corticosteroids are rarely used in combination. Combination therapy in our setting, is prescribed
without taking into consideration the ARIA classification.
General informations. This study was conducted at the Douala General Hospital and was presented as
thesis by a physician as end of study work at the Faculty of Medicine and Pharmaceutical Sciences in
Douala under the supervision of Pr Njock ENT specialist at General Hospital Douala, also author.
This study was not sponsored.
Competing interest statement.
We have no competing interest to declare.
Aknowledgements
Our thanks to all the medical and para medical staff of the Douala General Hospital for their support and
availability.
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