Implications for management: four case discussions

Journal of Family Practice, April, 2004

Case 1:

A young woman with nasal congestion and sneezing.

Steven A. Green, MD

University of California, San Diego, School of Medicine

* PRESENTATION

A 26-year-old woman presented to her family physician with an 8-month history of nasal congestion and sneezing. She serf-medicated with her sister's cetirizine (10 mg/day for 2 weeks), which reduced her symptoms by about 20%. She was interested in knowing the cause of her symptoms and what could be done to treat them. However, she preferred not to take any medicines.

* HISTORY

The intensity of the patient's symptoms varied (although they had worsened during the last few months) and were not accompanied by fever. Her nasal discharge was thick and yellow in the morning but cleared somewhat by midday. She also had recurrent sinus infections accompanied by facial pressure and fever; the most recent episode had occurred 6 months earlier. She did not have asthma and denied any medication allergies or illicit drug use. She smoked 10 cigarettes a day and owned a cat. Another physician had advised her to get rid of the cat, but she had not complied. The floors of her home were covered with wall-to-wall carpeting.

* EXAMINATION

Review of systems was normal The patient's nasal mucosa was swollen and pale; her posterior pharynx was erythematous but free of swelling or exudates. Her neck was supple with no adenopathy or thyromegaly. Her Lungs were dear, with no sign of wheezing. Her heart sounds were normal.

This case is representative of the many patients who self-medicate before seeing a physician: in some cases, symptoms have been present for years. Evaluation of congestion and sneezing should include a focused evaluation of symptoms and general evaluation of the medical history. The pattern, chronicity, and seasonality of symptoms and the presence, of coexisting medical conditions, such as asthma, allergic conjunctivitis, or rhinosinusitis, should be determined. Additionally, a detailed environmental history, including occupational exposures, and identification of precipitating factors may help to distinguish allergic from nonallergic rhinitis (Figure 1). Patients should be asked for a list of past medications that were directed at their symptoms, from which a list of effective and ineffective medications can be compiled.

The, impact of symptoms on quality of life also should be assessed. Patients with rhinitis may complain of fatigue due to sleep loss, headaches, poor concentration, repeated nose blowing, itchy and watery eyes, and general irritability. All of these things can have a negative impact on their ability to complete home and work responsibilities.

The physical should include examination of the nasal passageways, secretions, turbinates, and septum. Also, the presence of nasal polyps should be determined (Table 1). Pale, swollen nasal mucosa is typical in patients with rhinitis; bluish-gray mucosa may be seen in patients with severe mucosal edema. Unfortunately, distinguishing between allergic and nonallergic rhinitis can be difficult based on mucosal appearance because both may present with mucosal pallor, edema, or hyperemia. (1)

* MANAGEMENT

A working diagnosis of allergic rhinitis was made, and blood was drawn for specific IgE testing. The patient was given a prescription for cetifizine (10 mg/d).

Results of the blood test, which included 12 inhalant allergens endemic to the area, showed no significant IgE elevations. Therefore, the diagnosis was revised to nonallergic rhinitis and earlier plans to suggest allergen avoidance measures were aborted. The symptomatic benefit obtained from cetirizine was judged to be insignificant and attributed to a possible placebo effect; therefore, the drug was discontinued.

The patient was tow that her smoking probably aggravated her congestion and was advised to quit. She declined a prescription for nasal steroids, saying that she did not want a medication that had to be used every day. Over-the-counter pseudoephedrine, taken as needed, was suggested as an alternative to nasal steroids.

In this case, results of specific IgE blood testing contradicted the diagnostic assumptions made on the basis of the clinical history and physical examination, resulting in a revised diagnosis of nonallergic rhinitis. The benefits of having performed specific IgE blood testing in this patient are readily apparent. She does not have to struggle with difficult avoidance measures, including the possibility that she will again be told to get rid of her cat. She now has a good reason to give up cigarettes. Needless drug therapy and potential referral to an allergy specialist have been avoided.

Seeing that this patient obtained partial relief from cetirizine, a clinician might be inclined to simply prescribe a second medication or switch to another, hopefully more efficacious, antihistamine. In hindsight, after IgE testing, such an approach would have been misguided and possibly ineffective.

The differential diagnosis of nonallergic rhinitis is extensive (Table 2); of these, vasomotor rhinitis is by far the most common. The etiology of vasomotor rhinitis is unclear, which accounts for its other name, idiopathic nonallergic rhinitis. The diagnosis for vasomotor rhinitis is one of exclusion: normal total IgE levels, negative specific IgE tests, and a lack of identifiable inflammation on nasal cytology. (2)