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Descriptive study of 226 patients with allergic rhinitis and asthma in Karaj city

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Abolhassan Farhoudi
Abolhassan Farhoudi
Abolhassan Farhoudi
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Seyed Alireza Razavi at Tehran University of Medical Sciences
Seyed Alireza Razavi
Zahra Chavoshzadeh at Shahid Beheshti University of Medical Sciences
Zahra Chavoshzadeh
Marzyeh Heidarzadeh
Marzyeh Heidarzadeh
Marzyeh Heidarzadeh
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Abstract

The prevalence of allergic diseases such as asthma and allergic rhinitis is high in general population and aeroallergens are the most common allergens that cause air way inflammation.The aim of this study was an evaluation of clinical and laboratory findings in allergic patients and identification of the most common aeroallergen in these patients.A cross-sectional retrospective study was conducted on 226 allergic patients who were referred to allergic clinic of Karaj city, and skin prick test response to aeroallergens were studied. The most common risk factors in these patients were total IgE more than 100 IU/ml and a positive family history of atopy. Skin prick testing results showed that the most common aeroallergens were: herbacee II (62%), sycamore (57%), chenopodium (53%), tree mix (50%), herbacee III (47%), grass (43%), ash (40%), herbacee I (37%), cedar (27%), cockroach (25%), and mite D.P (19%), D.F (18%).High prevalence of skin reactivity to weeds (chenopodium and herbacee) and sycamore indicates variation in the prevalence of aeroallergen reactivity in different regions with different climates.
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BRIEF COMMUNICATION
Vol. 4, No. 2, June 2005 IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY /99
Descriptive Study of 226 Patients with
Allergic Rhinitis and Asthma
Abolhassan Farhoudi1, Alireza Razavi2, Zahra Chavoshzadeh1, Marzieh Heidarzadeh1,
Mohammad Hassan Bemanian1, and Mohammad Nabavi1
1 Department of Immunology and Allergy, Children's Hospital Medical Center, Tehran University of Medical Sciences,
Tehran , Iran
2 School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
ABSTRACT
The prevalence of allergic diseases such as asthma and allergic rhinitis is high in
general population and aeroallergens are the most common allergens that cause air way
inflammation.
The aim of this study was an evaluation of clinical and laboratory findings in
allergic patients and identification of the most common aeroallergen in these patients.
A cross–sectional retrospective study was conducted on 226 allergic patients who
were referred to allergic clinic of Karaj city, and skin prick test response to
aeroallergens were studied.
The most common risk factors in these patients were total IgE more than 100 IU/ml
and a positive family history of atopy.
Skin prick testing results showed that the most common aeroallergens were:
herbacee II (62%), sycamore (57%), chenopodium (53%), tree mix (50%), herbacee III
(47%), grass (43%), ash (40%), herbacee I (37%), cedar (27%), cockroach (25%), and
mite D.P (19%), D.F (18%).
High prevalence of skin reactivity to weeds (chenopodium and herbacee) and
sycamore indicates variation in the prevalence of aeroallergen reactivity in different
regions with different climates.
Keywords: Allergy; Asthma; Prevalence; Rhinitis
INTRODUCTION
Asthma and rhinitis are the most common allergic
conditions. Allergic conditions have increased since
past decades, and posing a heavy burden on health
care systems.1
Asthma is a major cause of chronic morbidity and
mortality throughout the world that is characterized
by paroxysmal spasmodic narrowing of the bronchial
airway due to inflammation of the bronchial tree and
contraction of the bronchial smooth muscle.2
Corresponding Author: Abolhassan Farhoudi, M.D; Department
of Immunology and Allergy, Children's Hospital Medical Center,
Tehran University of Medical Sciences, Tehran, Iran. Tel: (+98 21)
6693 3926, Fax: (+98 261) 442 9200, E-mail:
afarhoudi@yahoo.com
Common risk factors include exposure to allergen
such as domestic dust mites, animals with fur,
cockroach, pollens and molds, occupational irritants,
respiratory infections, exercise, air pollution and
tobacco smoke. Allergic rhinitis is an inflammatory
condition of the nasal mucosa characterized by the
symptoms of pruritus, sneeze, discharge and
stuffiness induced by an IgE - mediated response.1
Aeroallergen with an origin from plants, animals,
molds and mites are the most common allergens
involved in allergic rhinitis. Allergic disorders are
diagnosed by a proper history, physical examination
and some paraclinical findings Serum total IgE,
eosinophylic count, specific IgE, skin prick test,
RAST test and respiratory function test. Asthma and
Study of Patients with Allergic Rhinitis and Asthma
100/ IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY Vol. 4, No. 2, June 2005
rhinitis are common comorbidities, suggesting the
concept of one airway, one disease.3
This study was designed for evaluation of co
existence of asthma and rhinitis, risk factors for
allergy such as family history of atopy, IgE level and
identification of the most common aeroallergen in
Karaj city of Iran.
PATIENTS AND METHODS
A cross-sectional retrospective study was designed
and 226 patients with diagnosis of allergic rhinitis or
asthma based on the criteria of GINA4 who had been
referred to a private allergic clinic in Karaj city during
years of 2002 – 2003 were selected.
Information chart of patients was reviewed which
included data about sex, age, symptoms and signs of
diseases (diagnosis of disease), pattern of allergic
diseases (seasonal or perennial), family history of
atopy, CBC results, level of IgE and response to
aeroallergen such as trees (sycamore , Ash, Beech
,Cedar , Alder , Elder) ,grass, weeds (herbacee I, II,
III, chenopodium), Cockroach, House dust and mite
(D.P and D.F). Data was analyzed with Epi-Info
version 6, program.
RESULTS
Among 226 patients with allergic rhinitis or
asthma or both, male/female ratio was 1.5/ 1. Age of
patients was between 2 to 59 years with a mean of
age: 13.5 ± 10.5 yr.
In this study, 55% of patients had asthma. 56%
allergic rhinitis and 24% had bronchial asthma
together with allergic rhinitis.
Seasonal pattern was seen in 38% of patients,
perennial pattern in 29% and 20% had perennial
pattern with exacerbation in some seasons.
Positive family history of atopy was seen in 72%
of patients, 28% had Eosinophil count more than
300/mm3 and 71% had total IgE more than 100IU/ml.
In skin prick test, 68% had positive SPT to at least
one of the aeroallergens. Frequency of positive tests
to individual allergen is depicted in table 1.
The most common aeroallergens were herbacee II
(62%), sycamore (57%), chenopodium (53%), tree
mix (50%), herhacece III (47%), grass (43%), ash
(40%), herbacess I (37%), ceder (27%), cockroach
(25%), D.P (19%), D.F (18%). Other pollens such as
Beech, Birch, Alder, and Elder had little importance
because positive SPT to these allergens were less than
5%.
Table 1. Frequency of most common positive skin prick
test to the aeroallergens among 226 patients with allergic
symptom in Karaj city.
Allergen
Number of
subjects with
positive SPT
% frequency of
all positive
cases
Herbacee II 140 62%
Sycamore 128 57%
Chenopodium 120 53%
Tree mix 113 50%
Herbacee III 106 47%
Grass 97 43%
Ash 90 40%
Herbacee I 83 37%
Cedar 61 27%
Cockroach 56 25%
D.P 43 19%
D.F 41 18%
DISCUSSION
Common pathophysiology in allergic rhinitis and
asthma result to the important one airway , one
disease.3 Between 60 to 78% of patients who have
asthma have coexisting allergic rhinitis that they are
described better as a continuum of inflammation
involving one common airway. In our study 24% had
bronchial asthma together with allergic rhinitis.
Approximately, 20% of allergic rhinitis is strictly
seasonal, 40% perennial and 40% mixed.5 In this
study, 38% patients had seasonal pattern and 29%
perennial pattern and 20% mixed , so seasonal pattern
was the most common pattern witch may be due to
regional herbal geography.
The UK postal survey found a prevalence of
perennial diseases of 21%.6
Serum IgE greater than 100 IU/ml and family
history of atopy are risk factor for development of
allergic diseases. 72% of patients had positive family
history of atopy and 71% had IgE level more than 100
Iu/ml.
Aeroallergens are the prominent causes of allergic
symptoms in patients with asthma or allergic rhinitis.
In this study 68% of patients were sensitive to
aeroallergen but 26% had negative skin prick test in
A. Farhoudi, et al.
Vol. 2, No. 4, June 2005 IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY /101
spite of classic clinical findings of allergic rhinitis or
asthma, local generation of IgE provides an
explanation for this group.3
Pollens were the most common aeroallergen in
patients with allergic diseases in Karaj city. Among
pollens, weeds such as herbacee and chenopodium
had the highest rate of sensitization and trees such as
sycamore ash and grass were next in importance.
Cockroach, dust and dust mite including D.P and
DF had significant reaction.
In a similar study in Shiraz city, weeds and grasses
were the most common aeroallergens in patients with
allergic rhinitis.8
In United Arab Emirates, the most common
reactions were: Mesquitec, Grass mix, Cotton wood,
Bermuda grass, Kocki, Acacia, Alfalfa, Cheno-
podium, Date palm, Cockroach, House dust and Dust
mite.9
Based on our knowledge about dry climate and
regional herbal geography these results were
expected.
In contrast , house dust mite were reported to have
the highest rate of sensitization among Malaysian
asthmatic patients 10 and patients with allergic rhinitis
in Thailand,11 Singapore12 and Mexico city.13
This difference also was expected since mite tends
to require high humidity and moderate temperature to
thrive, whereas Karaj city had a dry climate.
Pollens such as weeds family and sycamore are
the major aeroallergen in Karaj city and this high
prevalence of skin reactivity to weeds and sycamore
denote to variation in the prevalence of aeroallergens
reactivity in different region with different climates.
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... The studies conducted in Iran depend on the study time and area. The aeroallergens such as mites and trees (13,14), herbaceous grass and grass (15,16), and food allergens such as egg yolk (17), peanuts and walnuts (18), and milk (19) have been identified as the most common allergens related to urticaria. The latest study in the Iranian population to identify allergens associated with pediatric Copyright © 2019, Author(s). ...
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... [5] Due to the high prevalence of AR, it affects community as impaired quality of life and related diseases such as atopy and asthma. [1] In various studies, it is reported that this disease is developing whole around the world; [6] although AR is not a fatal disease, it often leads to change and loss of quality of patients' life. The patients suffer from different problems such as impairment of behavior, learning, and memory. ...
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Full-text available
  • Jul 2018
Abstract Backgrounds and Objectives: House dust mites and cockroaches are I mportant indoor allergen sources causing allergic rhinitis and asthma. The aim of this study was to investigate the house dust mite and cockroach prevalence using Skin prick test (SPT). Materials and Methods: In this study 407 allergic rhinitis and asthmatic patients were evaluated. All patients were tested with the aeroallergens using House dust mix, Dermatophagoides farina, Dermatophagoides pteronyssinus and cockroach mix. Data were analyses by Statistical analysis. Results: Total number of 407 patients 212 (52%) males and 195(48%) females, age Between 4 -70 years, were studied. In asthmatic and allergic rhinitis, the respective positive percentages for house dust,Dermatophagoides pteronyssinus, Dermatophagoides farina and cockroaches were 23.3%, 31.7%, 35.6% and 32.9% respecively. Total IgE level elevated in over half of allergic patients. Conclusion: A relatively high prevalence of mites and cockroach sensitivity was found in our study. These figures are is similar with other reports from hot and humid areas. Keywords: Allergy, Mite, Cockroach, Ahvaz* Corresponding author : E-mail: shakurnia@yahoo.com (PDF) Mite and Cockroach Allergy in Patients with Respiratory Allergies A Report from Ahvaz. Available from: https://www.researchgate.net/publication/326438712_Mite_and_Cockroach_Allergy_in_Patients_with_Respiratory_Allergies_A_Report_from_Ahvaz [accessed Feb 22 2019].
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An analysis of skin prick test reactions in asthmatics in a hot climate and desert environment
Article
Full-text available
  • Nov 2002
Studies have shown that allergens are very important sensitizing agents in patients with asthma. Respiratory disorders such as asthma and allergic rhinitis are common in the United Arab Emirates, (UAE). The aim of this study was to investigate the relationship between allergen specific IgE antibodies and skin test reactivity in patients with asthma in hot climate and desert Arabian country. A hospital-based prospective study conducted. Tawam Teaching Hospital, Al-Ain, UAE. 327 adult patients recruited with respiratory, dermatologic and ophthalmologic diseases of suspected allergic origin who attended Tawam Teaching Hospital of Faculty of Medicine, Al Ain, UAE, during three years from 1996 to 1998. Skin Prick Test (SPT) and radioallegosorbent tests (RAST) were performed on 327 patients for common allergens. The blood sample was taken for measuring specific IgE concentration. There were 327 UAE patients of whom 117 (35.8%) were males and 210 (64.2%) were females. The population sample had a higher prevalence of diagnosed asthma among females (48.1%) than in males (36.7%). Skin prick testing showed that 244 patients (74.6%) had positive results, and 83 patients (25.4%) were found to be skin test negative. 44% had a positive family history of asthma. The twelve most common reactions in the United Arab Emirates were: Mesquite (45.5%), Grass Mix (40.7%). Cottonwood (33.1%), Bermuda Grass (31.3%), Kochi (25.8%), Acacia (25.6%), Alfalfa (22.9%), Chenopodium (19.6%), Date palm (13.8%), Cockroach (14.7%), house dust (11.9) and Dust mite (9.5%). Total IgE level (> 100 kU/l) was strongly associated with history of wheeze (p = 0.019), asthma (p = 0.01) and allergic rhinitis (p < 0.0001), atopy (p < 0.0001) and the presence of specific IgE antibodies to grass pollen (p < 0.0001), mite (p = 0.008) and cockroaches (p = 0.025). The present study revealed that hypersensitivity to pollens, house dust, dust mite and cockroach was common. The family history, environment, and airborne allergens are identified to be risk factors for asthma and other allergic diseases in Arabian Gulf Countries.
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Prevalence of Aeroallergens in Allergic Rhinitis in Shiraz
Article
Full-text available
  • Jan 2004
Allergic rhinitis is an extremely common disease worldwide. Aeroallergens are very often involved in allergic rhinitis and their prevalence may vary in different regions. The causative allergens of allergic rhinitis in our area are unknown.The purpose of this study was to determine the prevalence of skin reactivity to different aeroallergens in patients with allergic rhinitis in the city of Shiraz, Iran.A total of 212 patients who were referred to Motahari Allergy Clinic with chronic rhinitis were subjected to skin prick test (SPT) with a series of common allergenic extracts including grasses, weeds, trees, house dust mites and moulds. One hundred and thirty two subjects (62.2%) had positive SPT to at least one aeroallergen. Male to female ratio was 1.2 and mean age was 18.2 years. The prevalence rates for allergen groups were: pollens (92.4%), mites (22.7%) and moulds (8.3%). Among 122 patients reactive to pollens, 92 (75.4%) showed skin reactivity to weeds, 78 (63.9%) to grasses and 68 (55.7%) to trees. Polysensitization was common, with 75.7% of all sensitized patients being positive to more than one aeroallergen.Pollens are the main sensitizing allergens among patients with allergic rhinitis in Shiraz. This pattern of prevalence was expected based on herbal geography, climate and also found to be compatible with the results from studies carried out in places with the same habitat.
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Epidemiology of seasonal and perennial rhinitis: Clinical presentation and medical history
Article
  • Jan 1992
Little is known about the epidemiology of rhinitis, particularly the perennial and non-allergic forms. The aim of this study was to compare the symptoms, atopic state, and medical history of individuals with seasonal and perennial rhinitis. Of 7702 adults aged 16-65 years registered with a London general practice, 2969 (30%) were screened by postal questionnaire. Samples of 113 subjects without rhinitis, 51 with seasonal symptoms alone, 128 with perennial symptoms and seasonal exacerbations were then interviewed. Atopic and non-atopic subjects were distinguished by skinprick testing with five common allergens. The estimated minimum prevalence of rhinitis was 24%: 3% had seasonal symptoms only, of whom 78% were atopic; 13% had perennial symptoms only, of whom 50% were atopic; and 8% had perennial symptoms with seasonal exacerbations, of whom 68% were atopic. Seasonal rhinitis was characterised by sneezing, itching, and a high prevalence of diurnal variation in symptoms. The most common provoking factors were dust, pollens, and infections. By comparison, perennial rhinitis was characterised by a higher prevalence of nasal blockage and catarrh, and a lower prevalence of diurnal variation and provocation by pollen. There were no significant differences among the groups in the sociodemographic characteristics examined. Subjects with seasonal rhinitis were more likely to be atopic and to have eczema and a family history of hayfever than those without rhinitis. Those with perennial rhinitis were more likely to have past or current eczema or migraine, be wheezy or labelled asthmatic, or have a family history of nose trouble other than hayfever. Subjects with both seasonal and perennial symptoms presented an intermediate clinical picture. Seasonal and perennial rhinitis differ in their atopic state, clinical presentation, and medical history. The extent to which these differences are genetically or environmentally determined requires further investigation.
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One Airway, One Disease
Article
  • Mar 1997
The prevalence of asthma and allergic rhinitis is increasing in the general population, and a high proportion of new patients have coexisting upper and lower airway disease. Estimates show that 60 to 78% of patients who have asthma have coexisting allergic rhinitis. During the past decade, our understanding of asthma and allergic rhinitis has evolved. The historic perspective of these allergen-induced disorders as distinct and separate entities is being displaced by current thinking that they are described better as a continuum of inflammation involving one common airway. Therefore, traditional therapies originally indicated for allergic rhinitis and asthma are being reassessed to explore their potential utility in both upper and lower airway diseases. Recently, there has been a renewed interest in the role that histamines play in lower airway disease, and interest is increasing in the theory that leukotrienes, which are far more potent inflammatory mediators than histamines, play a role in upper airway disease. Given the pivotal role that leukotrienes play as potent inflammatory mediators in the pathophysiologic state of inflammation of both airways, leukotriene receptor antagonists recently have emerged as important therapeutic advances that have potential clinical utility in both asthma and allergic rhinitis.
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Aeroallergen sensitivity of Thai patients with allergic rhinitis Asian Pac
Article
  • Dec 1997
The aim of this study was to determine the aeroallergen sensitivity of allergic rhinitis patients. A total of 100 cases (female: 59, male: 41, aged between 10-59 years, mean age 27.9 years) who were diagnosed with allergic rhinitis by history and clinical presentation, underwent a prick skin test with 30 aeroallergens, and the important sensitizing allergens were assessed. Skin test reactivity showing > or = 3 mm wheal with erythema as the positive skin test, was recorded. The results of patients with positive skin tests follow. TREES: acacia 19%, mango 16%, coconut 12%. GRASSES: bermuda 17%, johnson 21%, timothy 16%, bahia 16% orchard 18%. WEEDS: pigweed 16%, kochia 14%. MOLDS: alternaria 11%, cladosporium 11%, aspergillus 12%, penicillium 16%, helminthosporium 16%, botrytis 15%, rhodotorula 20%, fusarium 26%, curvularia 26%, smut mix 11%, rust 9%. EPIDERMALS: cat 29%, dog 28%, feathers 37%. INDOOR ALLERGENS: house dust 72%, D. pteronyssinus 76%, D. farinae 79%, American cockroach 60%, German cockroach 41%, kapok 30%. Eighty-five percent of patients sensitive to house dust mites were positive to both D. pteronyssinus and D. farinae, indicating substantial cross-reactivity. The study shows that the house dust mite and the cockroach are important aeroallergen sensitizers among the Thai population, since more than half the patients were skin-test positive to the house dust mite and the cockroach.
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Sensitization to local dust mite fauna in Singapore
Article
  • Nov 1999
Recent studies showed the presence of a unique dust-mite fauna in the indoor environment of Singapore. Immediate hypersensitivity to these dust mites, along with other known indoor allergens, may play a role in the pathogenesis of allergic respiratory diseases. This study evaluated the sensitization rates of the local atopic population to these allergens. The skin prick test was performed on a total of 391 individuals (289 patients with asthma and/or allergic rhinitis and 102 healthy controls) using extracts of six species of local dust mites (Austroglycyphagus malaysiensis, Blomia tropicalis, Dermatophagoides pteronyssinus, D. farinae, Sturnophagoides brasiliensis, and Tyrophagus putrescentiae) and 10 other common indoor allergens. Total serum IgE and specific IgE to these dust mites were also quantified with the fluorescence allergosorbent test (FAST). The sensitization rates among patients with asthma and/or allergic rhinitis to dust mites and other inhalant allergens tested (via skin prick tests) were as follow: B. tropicalis (96.2%), D. pteronyssinus (93.4%), D. farinae (92.3%), A. malaysiensis (78.2%), S. brasiliensis (71.6%), T. putrescentiae (71.3%), canary feathers (69.9%), Periplaneta americana (cockroach) (59.5%), Blattella germanica (cockroach) (56.4%), mosquito (Aedes sp.) (46.4%), dog epithelia (mixed breed) (34.3%), kapok seed (31.8%), cat hair (29.1%), Aspergillus fumigatus (20.8%), Penicillium notatum (18.0%), and Candida (Monilia) albicans (9.3%). All patients were observed to react to at least three of the six dust-mite extracts, with 254/289 (87.9%) reacting to at least five or to all six. Skin prick responses to the dust mites were found to correlate with the corresponding specific IgE levels quantified by FAST (P<0.001). In addition, specific IgE levels to D. pteronyssinus and D. farinae were highly correlated (Spearman's rank coefficient = 0.76, P<0.001), as were those to B. tropicalis and A. malaysiensis (r = 0.60, P<0.001). Asthma and/or allergic rhinitis patients were highly sensitized to the local dust-mite fauna. Thus, these dust mites should be considered important allergenic sources of this region.
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Skin prick test reactivity to common aeroallergens in asthmatic patients with and without rhinitis
Article
  • Jan 2003
The aim of this study was to investigate the prevalence of skin prick test (SPT) reactivity to common aeroallergens among Malaysian asthmatic patients with and without rhinitis. An SPT using eight aeroallergens (Dermatophagoides pteronyssinus, Dermatophagoides farinae, cat fur, cockroach, Acacia sp., Bermuda grass, Aspergillus fumigatus and Aspergillus niger) was performed on 206 asthmatic patients. One hundred and forty patients (68%) were reactive to at least one of the aeroallergens. Among the SPT-positive patients, a positive prick test reaction to the house dust mites, D. pteronyssinus (93.6%), and D. farinae (81.4%) was most common, followed by cat fur (20.0%), cockroach (7.9%), Bermuda grass (7.9%), Acacia sp. (7.9%), A. fumigatus (0.7%) and A. niger (0.7%). A history of rhinitis was elicited in 111 (53.9%) patients and 95 (85.3%) of these patients were SPT-positive compared with only 45 (47.4%) of 95 patients with asthma symptoms alone (P < 0.001). The presence of rhinitis and a young age of onset of asthma were independent factors for positive SPT reaction to at least one of the aeroallergens. The prevalence of SPT reactivity to common aeroallergens is high among Malaysian asthmatics, particularly in those with an early age of onset and in those with coexisting rhinitis.
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The Asthma and Allergic Rhinitis Link
Article
  • Nov 2003
During the past 10 years, our understanding of asthma and allergic rhinitis (AR) has evolved. The historic perspective of these allergen-induced disorders as distinct and separate entities is being displaced by current thinking that they are described better as a continuum of inflammation involving one common airway. Therefore, traditional therapies originally indicated for AR and asthma are being reassessed to explore their potential value in both upper- and lower-airway diseases. Recently, there has been a renewed interest in the role that histamines play in lower-airway disease, and interest is increasing in the leukotrienes (LTs), which are far more potent inflammatory mediators than histamines, and the role they play in upper-airway disease. Given the pivotal role that LTs play as potent inflammatory mediators in the pathophysiological state of inflammation of both airways, LT receptor antagonists recently have emerged as important therapeutic advances that have potential clinical value in both asthma and allergic rhinitis. The prevalence of asthma and AR is increasing in the general population, and a high proportion of new patients have coexisting upper- and lower-airway disease. Estimates show that 60-78% of patients who have asthma have coexisting AR. The following review discusses the epidemiology of asthma and AR, provides evidence for common pathophysiological mechanisms, and discusses a therapeutic approach that has positive effects on both diseases and may maximize benefits and outcomes for patients with concomitant asthma and AR.
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Nelson text book of pediatrics
  • Jan 2004
  • 759-760
  • H Milgram
  • Dym Leung
  • R E Behrman
  • R M Kliegman
  • H B Jenson
Milgram H, Leung DYM. Allergic rhinitis. In: Behrman RE, Kliegman RM, Jenson HB. Nelson text book of pediatrics. Philadelphia: W.B Sunders, 2004: 759-760.
Allergic and non allergic rhinitis. Natural history, development and prevention of allergic disease in childhood
  • Jan 2003
  • 1391-1407
  • P H Howarth
  • E Von Mutius
  • F D Martinez
Howarth PH, von Mutius E, Martinez FD. Allergic and non allergic rhinitis. Natural history, development and prevention of allergic disease in childhood. In: Middleton's allergy principles and practice. USA: Mosbey, 2003: 1391-407.