Emerging endotypes of dermatophagoides pteronyssinus-induced rhinitis and risk of chronic rhinosinusitis with nasal polyps
Published: January 20, 2022
Observation of the natural history of two emerging endotypes of allergic rhinitis, local-sensitization rhinitis (LAR) and dual-allergic rhinitis (DAR), compared with systemic-sensitization rhinitis (SAR), could improve knowledge of the role of allergy in chronic rhinosinusitis with nasal polyps (CRSwNP).
De Marchi et al. in The Journal of Allergy and Clinical Immunology: In Practice conducted a prospective observational study over 15 years on a cohort of 999 patients with persistent or perennial allergic rhinitis induced by Dermatophagoides pteronyssinus (DP): 468 with SAR, 333 with LAR, and 198 with DAR. The diagnosis of SAR and LAR was carried out according to the classical criteria. Dual-allergic rhinitis was characterized by the coexistence of seasonal rhinitis with positive SPT/sIgE to pollen and local allergic rhinitis caused by DP (positive nasal allergen provocation test or NAPT with DP without evidence of systemic atopy sensitization to house dust mites). During 15 years of follow-up, 194 patients developed CRSwNP with a higher rate of LAR (28.2%) and DAR (22.2%) than SAR (12%). For LAR and DAR, 7.5% and 10.6% of patients developed adult-onset asthma temporally linked to CRSwNP in 68% and 71.4% of cases, respectively. A total of 858 patients with rhinitis had delayed hypersensitivity to DP, as indicated by a positive atopy patch test (DP-APT). Moreover, DP-APT was an independent predictor factor for CRSwNP and had elevated positive and negative values for localized allergic disease of the nasal mucosa.
De Marchi et al. concluded that endotypes of DP-induced allergic rhinitis represent risk factors for CRSwNP. Patients with LAR and DAR are more at risk than those with SAR. In these emerging endotypes, progression toward CRSwNP is often associated with the development of adult-onset asthma.
The study is important because the impact of these endotypes on CRSwNP and the prevalence and clinical significance of the atopy patch test in these patients have never been investigated. Moreover, these results suggest that in the clinical practice, when the patient is suffering from persistent or perennial rhinitis, sensitization to DP should be sought even in the absence of the classic IgE-mediated hypersensitivity tests or in the presence of systemic sensitization for pollen alone. In these cases, DP-APT should be included in the diagnostic workup. Finally, the study offers the rationale for considering future research and intervention strategies (e.g. allergen immunotherapy) targeting local allergy to DP in LAR and DAR endotypes in an attempt to prevent the development of CRSwNP and progression toward adult-onset asthma.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.