Case Study – Allergic Rhinitis
Pathophysiology & Clinical Findings of the Disease
Identify the correct hypersensitivity reaction:
The symptoms the patient exhibits are typical of allergic rhinitis, the most prevalent type 1 hypersensitivity response mediated by IgE (Abbas et al., 2021). Allergy rhinitis occurs when an allergen is inhaled and causes nasal membrane inflammation. This kind of reaction goes under a few different names: allergic reaction, instant reaction. This is corroborated by the patient’s outward appearance and the amelioration of her symptoms during her Caribbean vacation. Therefore, the allergen is not present in the patient’s immediate surroundings. Treatment, such as antihistamines, is typically required to confirm AR. The correct sensitivity response seems to be established if the patient improves while using this medication.
Explain the pathophysiology associated with the chosen hypersensitivity reaction:
An allergic reaction, also known as a type 1 hypersensitivity reaction, results from a complex interaction between several immune system components. When an allergen comes into contact with the body, it is quickly taken up by antigen-presenting cells such as dendritic cells and macrophages. After ingesting the antigen, B cells produce allergen-specific antibodies known as IgE. Nasal basophils and mast cells might be targeted by IgE antibodies (Abbas et al., 2021). When exposed to the allergen for a second time, the protein on the mast cell surface will bind to the IgE antibodies. The classic symptoms of allergic rhinitis result from the mast cells’ production of inflammatory chemicals such as Histamine, leukotrienes, and cytokines. These bring on allergy rhinitis symptoms. Histamine is the most potent of these messengers and is responsible for most of the unpleasant effects of allergic rhinitis. Rhinorrhea, or a stuffy or runny nose, is one of these symptoms. Nasal membrane enlargement and increased mucus production result from releasing these mediators. This occurs because the mediators increase vascular permeability.
Identify at least three subjective findings from the case:
The patient presents to the primary care office with a chief complaint of nasal congestion and recurrent sinus infections. Upon further assessment, the nurse practitioner observed that the patient had various subjective symptoms that indicated allergic rhinitis. These subjective symptoms included rhinorrhea, sneezing, and nasal stuffiness that were present daily with no relief. The patient also reported that her symptoms improved while away from her home environment, such as while on a Caribbean cruise, but returned once she returned home. Additionally, the physical exam revealed eyelid redness and swelling, conjunctival swelling and erythema, allergic shiners, allergic creases, and inflamed nares. These subjective and objective findings indicate allergic rhinitis, a hypersensitivity reaction.
Identify at least three objective findings from the case:
The patient presented with several symptoms upon physical examination. This included eyelid redness and swelling, conjunctival swelling and erythema, allergic shiners, allergic crease, and inflamed nares. These objective findings are consistent with the diagnosis of allergic rhinitis, a type of hypersensitivity reaction characterized by nasal congestion, rhinorrhea, sneezing, and itching. It is caused by a person inhaling something they are allergic to, such as animal dander or pollen. Allergic rhinitis can be classified by the temporal pattern of exposure to a triggering allergen, the frequency of symptoms, and the severity. With proper diagnosis and treatment, allergic rhinitis can be managed to reduce symptoms and improve quality of life.
Management of the Disease
*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.
Identify two strongly recommended medication classes for the treatment of the condition and provide an example (drug name) for each:
Intranasal corticosteroids are recommended as the first treatment for allergic rhinitis, according to the clinical practice guidelines for its management (Almutairi et al., 2020). This kind of suggestion may be found in the clinical practice handbook. Recent research has shown that intranasal injection of corticosteroids is one of the most effective methods of treating allergic rhinitis and preventing its symptoms from worsening. Fluticasone (Flonase), triamcinolone (Nasacort), ciclesonide (Omnaris), and mometasone (Nasonex) are all examples of intranasal corticosteroids. The effectiveness of these drugs depends on their ability to reduce inflammation in the nasal passages and lessen the body’s susceptibility to environmental allergens.
The suggestion also says that antihistamines or spray antihistamines can be used as a second-line treatment for allergic rhinitis. Antihistamines help reduce allergic rhinitis symptoms by stopping Histamine, the main chemical that causes allergic reactions, from doing its job. Hay fever is also treated with antihistamines. There are many different kinds of antihistamines, including loratadine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra). Intranasal antihistamines like azelastine (Astelin) and olopatadine (Patanase) are also available. By stopping Histamine from connecting to its receptors, these medicines stop the production of inflammatory molecules that cause allergy symptoms.
Describe the mechanism of action for each of the medication classes identified above:
The best way to treat allergic rhinitis is to use inhaled antihistamines through the nose. These medicines make the tissue that lines the nasal passages less inflamed. By reacting with glucocorticoid receptors on the surface of cells in the nasal passage, they stop the body from making chemicals that cause inflammation, such as Histamine, cytokines, and leukotrienes (Seidman et al., 2015). Because of this relationship, fewer of these chemicals are being made. Because of this, the symptoms of allergic rhinitides, such as stuffy nose, coughing, and a runny nose, are finally relieved. Intranasal corticosteroids are often the first treatment for allergic rhinitis because they make the symptoms less severe.
Antihistamines are another way to treat the symptoms of allergic rhinitis. Since Histamine is the main chemical that causes allergic responses, these medicines may only work if they stop the release of Histamine (Seidman et al., 2015). Mast cells make Histamine when they come in contact with allergens. This sets off a chain of inflammatory events that lead to the symptoms of allergic rhinitis. Antihistamines lessen the signs of allergic rhinitis by stopping the body’s Histamine from doing its usual job. Antihistamines like azelastine (Astelin) and olopatadine (Patanase) can be breathed in instead of eaten. These medicines may work directly on the nasal tissue, which would help relieve symptoms more quickly and in more ways.
Identify two treatment options that are NOT recommended (I.e., recommended against):
The clinical practice guideline for treating allergic rhinitis says that decongestants and intranasal liquid irrigations should not be used (Mitsias et al., 2020). Instead, the suggestion says to take both antihistamines and drugs that reduce inflammation at the same time. Decongestants narrow the blood vessels in the nasal tissue and can briefly help with stuffy noses. Still, they are not suggested because they might cause a reoccurrence of the congestion. Intranasal saltwater irrigations are not recommended because there is not enough proof to show that they work and they might cause harm.
References
Abbas, M., Moussa, M., & Akel, H. (2021, July 21). Type I Hypersensitivity Reaction. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560561/
Almutairi, T. A., Aldayel, A. A., Aldayel, A. S., Alotaibi, F., & Alhussain, H. A. (2020). Safety Concerns of Nasal Corticosteroids Usage in Patients With Allergic Rhinitis. Cureus. https://doi.org/10.7759/cureus.11651
Kawauchi, H., Yanai, K., Wang, D.-Y., Itahashi, K., & Okubo, K. (2019). Antihistamines for Allergic Rhinitis Treatment from the Viewpoint of Nonsedative Properties. International Journal of Molecular Sciences, 20(1), 213. https://doi.org/10.3390/ijms20010213
Mitsias, D. I., Dimou, M. V., Lakoumentas, J., Alevizopoulos, K., Sousa-Pinto, B., Fonseca, J. A., Bousquet, J., & Papadopoulos, N. G. (2020). Effect of nasal irrigation on allergic rhinitis control in children; complementarity between CARAT and MASK outcomes. Clinical and Translational Allergy, 10(1). https://doi.org/10.1186/s13601-020-00313-2
Seidman, M. D., Gurgel, R. K., Lin, S. Y., Schwartz, S. R., Baroody, F. M., Bonner, J. R., Dawson, D. E., Dykewicz, M. S., Hackell, J. M., Han, J. K., Ishman, S. L., Krouse, H. J., Malekzadeh, S., Mims, J. (Whit) W., Omole, F. S., Reddy, W. D., Wallace, D. V., Walsh, S. A., Warren, B. E., & Wilson, M. N. (2015). Clinical Practice Guideline: Allergic Rhinitis. Otolaryngology–Head and Neck Surgery, 152(1_suppl), S1–S43. https://doi.org/10.1177/0194599814561600
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Question 
The purpose of this assignment is to apply hypersensitivity pathophysiological concepts to explain assessment findings of a patient with Allergic Rhinitis. Students will examine all aspects of the patient’s assessment including: Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH), Family History (FH), Social History (SH), Review of Systems (ROS), and Medications and then answer the questions that follow on the provided Comprehensive Case Study template.
Case Study – Allergic Rhinitis
Activity Learning Outcomes
Through this assignment, the student will demonstrate the ability to:
Analyze the case to arrive at the type of hypersensitivity reaction that the patient is exhibiting. (CO1)
Explain the pathophysiology of the identified hypersensitivity reaction. (CO1)
Identify all subjective and objective information provided in the case. (CO3)
Explain, using pathophysiology, the rationale for each subjective and objective finding. (CO1, CO3)
Identify two types of medications that are strongly recommended for the treatment of allergic rhinitis according to the clinical practice guidelines on the management of allergic rhinitis. (CO2, CO5)
Explain the mechanism of action of the two medication classifications and include how the symptoms of allergic rhinitis are alleviated when taken. (CO2, CO5)
Case Study Scenario
A 35-year-old woman presents to the primary care office with a history of nasal congestion that has worsened over time and recurrent sinus infections. She considered herself healthy until about 12 months ago when she began experiencing rhinorrhea, sneezing, and nasal stuffiness that “seems to never go away”. She noticed that her rhinorrhea greatly improved when she attended her family reunion on a two-week Caribbean cruise but returned after being home a few days. She lives with her husband and 5- year-old child. They have two household pets: a dog that has lived with them for the last 4 years and a cat who joined the family 1 year ago. Upon exam, the NP observed eyelid redness and swelling, conjunctival swelling and erythema, allergic shiners (lower lid venous swelling), Allergic crease (lateral crease on the nose) and inflamed nares.
Case Study Questions
Pathophysiology & Clinical Findings of the Disease
Identify the correct hypersensitivity reaction.
Explain the pathophysiology associated with the chosen hypersensitivity reaction.
Identify at least three subjective findings from the case.
Identify at least three objective findings from the case.
Management of the Disease
*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.
Identify two strongly recommended medication classes for the treatment of the condition and provide an example (drug name) for each.
Describe the mechanism of action for each of the medication classes identified above.
Identify two treatment options that are NOT recommended (I.e., recommended against).