NR 507 Week 1 Case Study: Allergic Rhinitis

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, along with recurrent sinus infections. She considered herself healthy until about 12 months ago when she began experiencing persistent rhinorrhea, sneezing, and nasal stuffiness that “seems to never go away.” She noticed that her symptoms significantly improved when she attended her family reunion on a two-week Caribbean cruise, but the symptoms returned a few days after she got back home. The patient lives with her husband and 5-year-old child. They have two household pets: a dog that has lived with them for the last four years and a cat that joined the family one year ago. Upon examination, the nurse practitioner observed eyelid redness and swelling, conjunctival swelling and erythema, allergic shiners (lower lid venous swelling), an allergic crease (lateral crease on the nose), and inflamed nares.

Case Study Questions

Pathophysiology & Clinical Findings of the Disease

1. Identify the correct hypersensitivity reaction.
   • The patient is likely experiencing a Type I hypersensitivity reaction, commonly associated with allergic rhinitis. This reaction is IgE-mediated and occurs when the immune system overreacts to allergens such as pet dander, pollen, or dust mites.
2. Explain the pathophysiology associated with the chosen hypersensitivity reaction.
   • In a Type I hypersensitivity reaction, exposure to an allergen leads to the production of specific IgE antibodies by B-cells. These IgE antibodies bind to receptors on mast cells and basophils, sensitizing them to the allergen. Upon subsequent exposure to the same allergen, it binds to the IgE antibodies on the sensitized cells, triggering the release of inflammatory mediators such as histamine, leukotrienes, and prostaglandins. This release leads to the clinical manifestations of allergic rhinitis, including rhinorrhea, sneezing, nasal congestion, and itchy, swollen eyes.
3. Identify at least three subjective findings from the case.
   • Persistent rhinorrhea (runny nose)
   • Nasal stuffiness that does not improve
   • Sneezing that seems to be ongoing
4. Identify at least three objective findings from the case.
   • Eyelid redness and swelling
   • Conjunctival swelling and erythema
   • Allergic shiners and inflamed nares

Management of the Disease

1. Identify two strongly recommended medication classes for the treatment of the condition and provide an example (drug name) for each.
   • Intranasal corticosteroids: Example - Fluticasone propionate (Flonase).
   • Oral antihistamines: Example - Cetirizine (Zyrtec).
2. Describe the mechanism of action for each of the medication classes identified above.
   • Intranasal corticosteroids: These medications work by reducing inflammation in the nasal passages, thereby decreasing symptoms such as nasal congestion, sneezing, and rhinorrhea. They inhibit the production of inflammatory mediators and cytokines by suppressing the activity of immune cells involved in the allergic response.
   • Oral antihistamines: These drugs block the H1 histamine receptors, preventing histamine from binding and exerting its effects. By doing so, they reduce symptoms such as itching, sneezing, and rhinorrhea.
3. Identify two treatment options that are NOT recommended (i.e., recommended against).
   • Decongestant nasal sprays for long-term use: Medications like oxymetazoline (Afrin) are not recommended for prolonged use due to the risk of rebound congestion (rhinitis medicamentosa).
   • Oral corticosteroids for mild allergic rhinitis: Systemic corticosteroids are generally not recommended for treating mild allergic rhinitis due to the potential for significant side effects and complications with long-term use.

Conclusion

Allergic rhinitis is a common condition characterized by an IgE-mediated hypersensitivity reaction to environmental allergens. Accurate diagnosis and appropriate management, including the use of intranasal corticosteroids and oral antihistamines, can significantly improve the quality of life for affected individuals. Avoiding ineffective or potentially harmful treatments, such as long-term use of nasal decongestants and systemic corticosteroids for mild cases, is also crucial in the management of allergic rhinitis.

References:

1. National Institute for Health and Care Excellence (NICE). (2020). Allergic rhinitis: Management. Retrieved from https://www.nice.org.uk/guidance/ng87/chapter/Recommendations

1. American Academy of Allergy, Asthma & Immunology (AAAAI). (2019). Treatment of allergic rhinitis. Retrieved from https://www.aaaai.org/conditions-and-treatments/library/allergy-library/treatment-of-allergic-rhinitis