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Patient Story

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A 9-year-old girl presents to her pediatrician for constant nasal congestion, runny nose, and intermittent bouts of sneezing and itching. Her symptoms occur year-round with increased symptoms in the spring and fall. On examination she has dark circles under her eyes (“allergic shiners”; Figure 215-1), bilateral conjunctivitis (Figure 215-2), swollen, pale, inferior turbinates, and a copious clear watery nasal discharge (Figure 215-3). Over-the-counter antihistamines have helped minimally so she is given a prescription for a nasal steroid spray to use daily. This significantly improves but does not eliminate the symptoms. She is seen by an allergist who obtains a history that she sleeps on feather pillows, lives with two cats, and also has eye itching and redness when outside in the spring. Skin prick testing to local environmental allergens shows positive reactions to dust mites, cats, and grass and ragweed pollens (Figures 215-4 and 215-5). Recommendations for avoidance of the dust mites, cats, and the outdoor pollens were given. Her technique and adherence with the nasal steroids was discussed and she was given nasal antihistamines to treat breakthrough symptoms.

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FIGURE 215-1

Mouth breathing and “allergic shiners” evident in a young child with allergic rhinitis. (Used with permission from Brian Schroer, MD.)

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FIGURE 215-2

Conjunctival injection and chemosis in a patient with allergic conjunctivitis. (Used with permission from Strange GR, Ahrens WH, Schafermeyer RW, Wiebe R. Pediatric Emergency Medicine 3rd edition. Figure 69-1, New York: McGraw-Hill; 2009.)

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FIGURE 215-3

Right inferior turbinate hypertrophy with production of clear thin mucous typical of allergic rhinitis on nasal endoscopy in a young child. (Used with permission from Prashant Malhotra, MD.)

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FIGURE 215-4

Skin prick testing showing wheal and flare reaction before prick (A) and after 15 minutes (B). (Used with permission from Brian Schroer, MD.)

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FIGURE 215-5

Positive wheal and flare reactions to multiple tested allergens on Skin Prick Testing in a young child. (Used with permission from Brian Schroer, MD.)

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Introduction

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Allergic rhinitis is a syndrome of upper airway symptoms in patients who are sensitive to aeroallergens including but not limited to animal dander, dust mites, mold spores, pollen, cockroaches, and rodents. Many patients have a history of atopic dermatitis, allergic rhinitis and asthma that together make up the “atopic triad.” These symptoms may be present in a seasonal pattern or year-round with seasonal exacerbations.

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Synonyms

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