Documente Academic
Documente Profesional
Documente Cultură
By :
Iwin Sumarman
Faculty of Medicine Padjadjaran University
Dr. Hasan Sadikin General Hospital
Bandung - Indonesia
Chronic ongoing disease Factors :
- Environmental (allergenic and or nonallergenic)
- Genetics
- Immunity distrubances
- Suceptible to secunder infections
Distribution of PAR (symptoms in Indonesia
Symptoms
1)
2)
3)
Stage 2+3+4 Stage 3+4
Rhinorhea
98,1 55,0
80,2
41,8
Sneezing
97,6 53,3
87,1
46,4
N Congestion
47,4 30,0
52,3
15,3
N Itching
18,7 26,7
nd
nd
Adapted from:
1) Sumarman et al. Hasan Sadikin Hosp. ENT-OPD patients (Bandung, 1992)
2) Suprihati et al Karyadi Hosp. ENT-OPD patients (Semarang, 1983)
3) Haryanto & Sumarman. (Population of Bandung City, 1999)
Allergic Rhinitis
DIAGNOSTIC Procedure:
-
3. Immunotherapy
(WHO Initiative ARIA 2000
Optional therapy:
Pharmacotherapy and/or surgery for complications Either diagnostic or management
of allergic rhinitis, present or future, needs a good understanding of allergic rhinitis
phatophysiology
Integrin family:
LFA-1, Mac-1, p150,95, VLA-4, VLA-6, Act-1
8 Adhesion molecules functions :
VCAM-1 (especially for EOS cells)
ICAM-1 and E-selectin (for EOS, Baso and Neutro cells)
Adhesion molecules functions on recruitment of inflammatory cells :
Blood vessel
Eos
in
air
cavi
ty
Eos
inTis
sue
Alergy Rhinitis
Symptoms:
* Rhinorrhea * Sneezing
* Congestion * Nasal Itchy
1 = trivial ; 2 = mild;
3 = moderate; 4 = severe
Sneezing Predominantly in EPR
Peptide endotelin-1
Leukotrien
Pruritus
Exclusively in EPR
Nasal itching and Palatal clicking
Histamine stimmulation on H1 receptor on C fibre
sensory nerve ending
Protaglandin may also constribute
Rhinorrhea
Excessive discharge from nasal mucous. membrane
Begin 3 min., last for approx. 20 to 30 min. after alergen challenge
Rhinorrhea (Histamine release from Mast cells)
Histamine on H1 receptor:
Acetylcholine
Sleep disturbances
Sleep disturbances
Scratch test
Patch test
Intracutan test
Skin prick test
Each test has own advantages and disadvantages and specific indication
Skin Prick Test
- Indonesian : Tes kulit tusuk (Tes kulit cungkit)
- Simple, save, painless, and preferably
- Single device (good enough and cheap)
- Multiple devices (better but more expensive)
- Volar region
- The prick be placed > 3 cm apart
Standardized extract
The best set: 6 allergen, but can more
No prick bleeding (in appropriate result)
Assesment: diam. wheal and flare (mm) (0, 1+, 2+, 3+ and 4+)
Indications:
If SPT negative
ID test
SET
wheal 0 = 4mm
wheal 15 < 5 mm (Negative resp)
wheal 15 > 5 mm (Positive resp)
SET interpretation
The endpoint is the next stronger dilution with a > 2mm larger wheal positive
response
0 minute wheal : 4 mm
15 minutes wheal:
#5
#4
#3
#2
# 1 Dilution
Normal response
5
7
9 mm
Endpoint is # 3
Abnormal response:
Flash response; Plateau response; Hourglass response Skin endpoint titration (SET)
The ultimate objective of SET are:
1. Safe initiate dose of immunotherapy (IT)
2. Decrease of interval of injection of IT
3. Usefull at prae seasonally or co-seasonally IT
4. Safe testing and treatment on patient with severe symptoms