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7UDC: 616.211-002-053.2-017
CLINICAL AND IMMUNOLOGICAL CHARACTERISTICS OF CHILDREN AND ADOLESCENTS WITH ALLERGIC RINITIS
ASHUROVA NIGORA GAFUROVNA
Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics and Gynecology No. 2 of the Bukhara State Medical Institute named after Abu Ali ibn Sino, Bukhara, Uzbekistan.
ORCID ID 0000-0003-2261-4188 NUROVA GUZAL UBAYDULLAYEVNA Candidate of Medical Sciences, Assistant of the Department of Otorhinolaryngology and Ophthalmology of the Bukhara State Medical Institute named after Abu Ali ibn Sino, Bukhara, Uzbekistan.
ORCID ID 0000-0003-2708-7874 KHURSANOVASLIDDIN MURAT UGLI Master of the Department of Otorhinolaryngology and Ophthalmology of the Bukhara State Medical Institute named after Abu Ali ibn Sino, Bukhara, Uzbekistan. ORCID ID 0000-0003-2690-6276
ABSTRACT
Under supervision were 60 children and adolescents aged 7-14 years (36 boys and 24 girls) with persistent moderate allergic rhinitis. The patients underwent general clinical, clinical and laboratory, instrumental, allergological and immunological studies. It was found that in the period of exacerbation of the disease, there is an increase in the absolute number of lymphocytes and monocytes in the blood, marked eosinophilia, significant changes in the content of populations and subpopulations of lymphocytes in the blood, an increase in IgG and IgM content, a marked increase in IgE in the blood serum, shifts in phagocytosis. In the period of clinical remission, the symptoms of the disease were absent in patients, normalization of the rhinoscopic pattern was noted, but eosinophilia and changes in a number of parameters of immunological reactivity were
preserved, which may be a sign of the organism's readiness for allergic reaction and exacerbation of the process under the influence of unfavorable environmental factors.
The received data suggest that therapeutic interventions aimed at correcting immune disorders should be included in combination therapy of children with persistent allergic rhinitis. To this end, native immunomodulators of the new generation (imunophane, polyoxidonium) and ozonotherapy, which have anti-inflammatory, detoxification, antioxidant and immunomodulatory effects, can be used and have no contraindications.
The results of the studies testify to the advisability of including children with persistent allergic rhinitis into therapeutic measures aimed at correcting of immune disorders.
Key words: children, allergic rhinitis, immunological reactivity.
КЛИНИКО-ИММУНОЛОГИЧЕСКАЯ ХАРАКТЕРИСТИКА ДЕТЕЙ ПОДРОСТКОВ С АЛЛЕРГИЧЕСКИМ РИНИТОМ
АШУРОВА НИГОРА ГАФУРОВНА
кандидат медицинских наук, доцент кафедры акушерства и гинекологии №2 Бухарского Государственного медицинского института имени Абу Али ибн Сино, г. Бухара, Узбекистан.
ORCID ID 0000-0003-2261-4188 НУРОВА ГУЗАЛ УБАЙДУЛЛАЕВНА кандидат медицинских наук, ассистент кафедры оториноларингологии и офтальмологии Бухарского государственного медицинского института имени Абу Али ибн Сино, г. Бухара, Узбекистан. ORCID ID 0000-0003-2708-7874
ХУРСАНОВ АСЛИДДИН МУРАТ УГЛИ магистр кафедры оториноларингологии и офтальмологии Бухарского государственного медицинского института имени
Абу Али ибн Сино, г. Бухара, Узбекистан.
ОИСЮ Ю 0000-0003-2690-6276 АННОТАЦИЯ
Под наблюдением находилось 60 (36 мальчиков и 24 девочки) детей и подростков школьного (7-14 лет) возраста с персис-тирующим среднетяжелым аллергическим ринитом. У пациентов проводили общеклинические, клинико-лабораторные, инструментальные, аллергологические и иммунологические исследования.
Установлено, что в периоде обострения заболевания у пациентов отмечалось увеличение абсолютного количества лимфоцитов и моноцитов в крови, выраженная эозинофилия, значительные изменения содержания популяций и субпопуляций лимфоцитов в крови, повышение содержания IgG и IgM, резко выраженное повышение содержания lgE в сыворотке крови, сдвиги показателей фагоцитоза. В периоде клинической ремиссии симптомы заболевания у пациентов отсутствовали, отмечалась нормализация риноскопической картины, но сохранялись эозинофилия и изменения ряда параметров иммунологической реактивности, что может быть признаком готовности организма к возникновению аллергической реакции и обострению процесса при воздействии неблагоприятных факторов внешней среды. Результаты исследований свидетельствуют о целесообразности включения в комплексную терапию детей с персистирующим аллергическим ринитом лечебных мероприятий, направленных на коррекцию иммунных нарушений. С этой целью могут быть использованы отечественные иммуномодуляторы нового поколения и озонотерапия, которые обладают противовоспалительным, дезинтоксикационным, антиоксидантным и иммуномо-дулирующим действиями, не имеют противопоказаний к
применению.
Ключевые слова: дети, подростки, аллергический ринит, иммунологическая реактивность.
ALLERGIK RINIT BILAN OG'RIGAN BOLALAR VA O'SMIRLAR KLINIK-IMMUNOLOGIK XUSUSIYATLARI
ASHUROVA NIGORA GAFUROVNA
t.f.n., №2 akusherlik va ginekologiya kafedrasi dosenti, Buxoro davlat tibbiyot instituti, Buxoro sh., O^zbekiston Respublikasi.
ORCID ID 0000-0003-2261-4188 NUROVA GUZAL UBAYDULLAYEVNA t.f.n., otorinolaringologiya va oftalmologiya kafedrasi assistenti, -Buxoro davlat tibbiyot instituti, Buxoro sh., O^zbekiston Respublikasi.
ORCID ID 0000-0003-2708-7874 XURSANOVASLIDDIN MURAT UGLI otorinolaringologiya va oftalmologiya kafedrasi magistri, Buxoro davlat tibbiyot instituti, Buxoro sh., O^zbekiston Respublikasi.
ORCID ID 0000-0003-2690-6276 ANNOTATSIYA
Kuzatuv ostida maktab yoshidagi (7-14yosh) 60 nafar (36 o'g'il va 24 qiz) allergik rinit bilan og'rigan bolalar va o'smirlar bo'ldi. Bemorlarga umumiy klinik, klinik laboratoriya, instrumental, allergologik va immunologik tadqiqotlar o'tkazildi. Kasallikning kuchayishi davrida bemorlarda qondagi limfotsitlar va monotsitlarning mutlaq sonining ko'payishi, aniq eozinofiliya, qondagi limfotsitlar populyatsiyalari va subpopulyatsiyalari tarkibidagi sezilarli o'zgarishlar, qondagi limfotsitlar sonining ko'payishi aniq landi. IgG va Ig M tarkibi, qon zardobida IgE miqdorining sezilarli darajada oshishi fagotsitoz ko'rsatkichlarini o'zgartiradi. Klinik remissiya davrida bemorlarda kasallik belgilariyo'q edi, rinoskopiya rasmining normallashishi qayd etildi, ammo eozinofiliya va
immunologik reaktivlikning bir qator parametrlarining o'zgarishi saqlanib qoldi, bu tananing allergik reaktsiyaga tayyorligini ko'rsatishi mumkin. salbiy ekologik omillar ta'sirida reaktsiya va jarayonning kuchayishi. Tadqiqotlar natijalari doimiy allergik rinit bilan og'rigan bolalarning kompleks terapiyasiga immunitet buzilishlarini tuzatishga qaratilgan terapevtik tadbirlarni kiritish maqsadga muvofiqligini ko'rsatadi. Buning uchun yallig'lanishga qarshi, detoksifikatsiya qiluvchi, antioksidant va immunomodulyator ta'sirga ega bo'lgan va foydalanishga qarshi ko'rsatmalarga ega bo'lmagan yangi avlodning mahalliy immunomo-dulyatorlari (nmunofan, polioksidonium) va ozon terapiyasidan foydalanish mumkin.
Kalit so'zlar: bolalar, o'smirlar, allergik rinit, immunologik reaktivlik.
Manifestations of persistent allergic rhinitis usually begin to occur in children in pre-school and primary school age. In the development of persistent allergic rhinitis, an important role belongs to hereditary predisposition. With atopy and hyperreactivity of the nasal mucosa, the starting factors of the disease are mainly household, epidermal and pollen allergens - [4, 2, 6].
Modern complex treatment of children and adolescents with persistent allergic rhinitis is based on the elimination of allergens, the use of decongestants, antihistamines, cromones and intranasal glucocorticosteroids - [1, 5].
However, despite the large number of studies on the problem of persistent allergic rhinitis in childhood, the nature of immune disorders in these patients requires further study.
It is also known that modern complex conventional therapy may not be effective enough and not ensure the onset of a long-term clinical remission in children suffering from persistent allergic rhinitis. In this regard, the results obtained by us in the study of systemic immunity in
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СТОРШОЛАРШГОЛОТИЖ
children with persistent allergic rhinitis, which allow us to substantiate a new approach to the complex therapy of patients, deserve attention - [3, 7, 8].
The aim of this study is to optimize the diagnosis of allergic rhinitis by studying clinical and immunological features in children and adolescents.
Material and methods
Under observation were 60 children aged 7-14 years (36 boys and 24 girls) with persistent moderate allergic rhinitis (AR), who underwent general clinical, clinical laboratory, instrumental, allergological and immunological studies.
Skin prick tests with household, epidermal and pollen allergens were performed in 60 patients with persistent moderate allergic rhinitis in the period of complete clinical remission, using allergens manufactured by NPO Allergen (Stavropol), according to the attached instructions; control samples with histamine f and extracting liquid were placed in parallel. The allergic reaction that occurred during testing was assessed 20 minutes after the test was performed and considered in the presence of a positive reaction to histamine and a negative reaction to the extracting liquid as diagnostically significant in the case of hyperemia and a blister on the skin at the site of the test. Assessment of scarification allergy tests in patients was carried out taking into account the severity of the local allergic reaction.
To assess the state of immunity in 60 patients with persistent moderate allergic rhinitis (AR) in the first 1-2 days of observation (the period of exacerbation) and after 17-20 days from the start of treatment (the period of clinical remission), the content of populations and subpopulations of lymphocytes (CD 3- a , CD 4- a , CD 8- a , HLA - DFU -l , CD 16-l, C D 20-l) in the blood, the immunoregulatory index (IRI) CD 4/ CD 8 was calculated, the content of immunoglobulins ( lg ) was studied G,
A, M, E, circulating immune complexes (CIC) in blood serum, indicators of phagocytic activity of neutrophils (FAN), phagocytic index (PI) and nitroblue tetrazolium reduction test (NBT-test) in the cytoplasm of neutrophils. The results of these studies in patients were compared with data obtained from 83 apparently healthy children of the corresponding age.
In order to determine the content of CD 3-, CD 4-, CD 8-, HLA - DR + -, CDI 6- and C D 20-lymphocytes in the blood of patients with allergic rhinitis, an indirect immunofluorescence reaction (IRIF) was used, where immunophenotyping was carried out with using sets of monoclonal antibodies LTZ, LT4, LT8, MCA HLA - DR , LT16 and LT20, manufactured by the Nizhny Novgorod OOO NPK "Preparat". The research results were expressed as percentages and absolute numbers. The immunoregulatory index CD 4/ CD 8 was the ratio of the percentage of CD 4 and C D 8 lymphocytes in the blood.
The content of immunoglobulins of classes G , A, M, E in the blood serum of patients with allergic rhinitis was determined by enzyme immunoassay (ELISA) in accordance with the instructions for the set of reagents "Immunoscreen-C, A, M, E ELISA-Best" (CJSC "Vector -Best, Novosibirsk); the results of the study of IgG , IgA , IgM in blood serum were expressed in g/l, and the results of the study of the content of IgE in blood serum - in IU/ml. The content of circulating immune complexes in the blood serum of patients with allergic rhinitis was determined by precipitation in a solution of polyethylene glycol (Belokrinitsky L.V., 1987); the results of these studies were expressed in units. opt. sq.
The phagocytic activity of neutrophils in patients with allergic rhinitis was assessed using 1.1 ^m latex particles (Sigma, USA) as a phagocytic object, according to the method of (Potapova S.G. et al., 1977); the results were expressed as a percentage. The phagocytic index was calculated as the average number of latex particles absorbed by one neutrophil. At the
same time, in patients with allergic rhinitis, a spontaneous NST-test was evaluated, counting the number of cells that form granules of insoluble diformazan (Petrov R.V. et al., 1992); the results were expressed as a percentage.
The results obtained in the study of laboratory and immunological parameters in patients with persistent moderate allergic rhinitis were processed by the method of variation statistics with the determination of the arithmetic mean (M), standard deviation (5) and standard error (m), the coefficient of significance of differences between compared values (p) using the Student-Fisher table - [3]. At the same time, correlation analysis was used to assess the relationship between shifts in some immunological parameters in patients - [3]. The processing of digital material was carried out on a personal computer using the Microsoft application office excel Mac 2011.
Results and its discussion
The observed children with persistent mild allergic rhinitis had a history of frequent acute respiratory infections, signs of drug and food allergies. Clinical manifestations of allergic rhinitis first appeared in patients of this group at the age of 4-5 years, exacerbations of the disease occurred year-round with an interval of 3-4 months and were associated with exposure to causally significant allergens, intercurrent infection, or eating intolerable foods.
It should be noted that the observed children with persistent moderate allergic rhinitis showed signs of polyvalent sensitization of the body. Thus, when performing skin prick allergy tests with different allergens, patients showed positive and sharply positive results: house dust allergens + house mite + library dust - 37%, house dust allergen -23%, house dust allergens + house mite - 12%, house allergens dust + house mite + pillow feather - 12%, house dust allergen + epidermal allergens of pets - 8%, house dust allergen + pollen allergens of cereal
grasses, weeds, birch - 8%.
In the period of exacerbation of the disease in children with allergic rhinitis , emotional lability and increased motor activity, sleep disturbances and decreased appetite were noted. All patients had a slight hoarseness and spasmodic cough, nasal congestion, difficulty in nasal breathing, itching in the nose, frequent sneezing, copious mucous or watery discharge from the nose. Allergic conjunctivitis was noted in 25% of patients. Rhinoscopic examination revealed swelling and cyanosis of the mucous membrane of the turbinates, sometimes with a marble pattern, white spots and mucus flow down the posterior pharyngeal wall in all patients. At the same time, hypertrophy of the posterior pharyngeal tonsil was noted in all patients. In patients, when listening to the lungs and heart, during an electrocardiographic study, no changes were found. Ultrasound examination revealed reactive changes in liver tissue in 32% of patients with persistent moderate allergic rhinitis, hypotonic biliary dyskinesia in 23% of patients with allergic rhinitis, reactive changes in pancreatic tissue in 28% of patients with allergic rhinitis, which is one of signs of atopy. Changes in clinical analyzes of urine and feces in observed children with persistent moderate allergic rhinitis during the period of exacerbation of the disease were not detected.
In the period of clinical remission, which occurred in patients with persistent moderate allergic rhinitis after an average of 14.8 ± 05 days from the start of observation and treatment, an improvement in well-being and a satisfactory general condition, normalization of appetite and restful sleep, disappearance of symptoms of the disease and normalization of the rhinoscopy picture were recorded. . At the same time, emotional lability remained in patients with allergic rhinitis in the period of clinical remission.
In patients with persistent moderate allergic rhinitis during the period of exacerbation of the disease, a slight decrease in the number of erythrocytes and a decrease in the level of hemoglobin, an increase in the
absolute number of lymphocytes, monocytes and eosinophils in the blood were noted. Upon the onset of clinical remission, patients showed an increase in the absolute number of eosinophils in the absence of significantly significant changes in other peripheral blood parameters.
The results obtained in the study of immunological reactivity in children with persistent moderate allergic rhinitis in periods of exacerbation and clinical remission are presented in the table.
Immunity indices in patients with AR (M±w)
Indicators Healthy children, n = 83 Patients wi th AR, n = 60
period of exacerbation remission period
CD3-a,% 64.10+1.25 72.33+1.59* 66.96+1.21
STS-I, 107I 1.04+0.07 1.98+0.17* 1.59+0.12*
CD4-a,% 49.30+0.80 41.73+1.88* 45.98+1.49*
C D 4-I, YuuI 0.73+0.03 0.91+0.11 0.71+0.07
CD8-a,% 25.50+0.50 32.27+1.67* 26.94+0.99
C D 8-I, Yu7I 0.36+0.01 0.59+0.05* 0.38+0.04
IRI CD4/CD8 2.10+0.06 1.51+0.17* 1.88+0.21
HLA-DR\n,% 19.50+1.06 13.68+1.69* 17.11 + 1.29
HLA-DR4n, 10Yn 0.33+0.02 0.40+0.05 0.36+0.04
CD1 6-I,% 18.30+1.95 12.68+1.13* 17.00+1.49
CD 16-I, 107I 0.37+0.05 0.65+0.05* 0.38+0.04
C D 20-I,% 9.30+0.77 11.65+0.82* 10.91+0.70
C D 20-I, Yu7I 0.17+0.02 0.31+0.03* 0.27+0.03*
IgG.r /I 8.90+0.14 11.18+0.39* 9.65+0.17*
IgA, g/I 0.86+0.03 1.02+0.13 1.05+0.19
IgM.r /I 1.10+0.04 1.70+0.10* 1.35+0.07*
IgE.ME /mI 91.00+26.20 530.30+40.97* 386.90+41.93*
CEC, unit opt. sa. 0.070+0.004 0.068+0.003 0.072+0.004
FAN,% 66.70+1.11 76.38+2.10* 71.08+1.98
FI 10.80+0.17 8.70+0.95* 10.01+0.32
NST-test,% 17.70+0.69 12.72+1.01* 16.65+0.80
Note: "*" - p < 0.05-0.001 compared with the indicators in practically healthy children.
In patients with allergic rhinitis in the period of exacerbation of the disease (table), there was an increase in the relative and absolute number of CD 3-lymphocytes, a decrease in the relative number of CD 4-lymphocytes, an increase in the relative and absolute number of CD 8-lymphocytes, an increase in the immunoregulatory CD index 4/ CD 8, a
decrease in the relative number of HLA - DR + - lymphocytes, a decrease in the relative number of CD 16 -lymphocytes with an increase in the absolute number of these cells, an increase in the relative and absolute number of CD 20-lymphocytes in the blood . In the period of clinical remission (table) in patients with allergic rhinitis, an increase in the absolute number of CD 3- lymphocytes, a decrease in the relative number of CD 4-lymphocytes and an increase in the absolute number of CD 20-lymphocytes in the absence of statistically significant changes in the relative and absolute number of other populations and subpopulations of lymphocytes in the blood.
In patients with allergic rhinitis in the period of exacerbation of the disease (table), an increase in the content of immunoglobulin G and immunoglobulin M was noted against the background of a pronounced increase in the content of immunoglobulin E in the blood serum. However, the content of immunoglobulin A and the concentration of circulating immune complexes in the blood serum of the general group of patients with allergic rhinitis in the period of exacerbation of the disease did not differ significantly from the values of these indicators in practically healthy children. In the period of clinical remission (table), patients with allergic rhinitis also showed an increase in the content of immunoglobulin G, immunoglobulin M, and immunoglobulin E, in the absence of significant changes in the content of immunoglobulin A and the concentration of circulating immune complexes in the blood serum.
In patients with allergic rhinitis in the period of exacerbation of the disease (table), an increase in the phagocytic activity of neutrophils was recorded with a decrease in the values of the phagocytic index and the NBT test. In the period of clinical remission, the indicators of phagocytosis in children with allergic rhinitis (table) did not differ significantly from the indicators of phagocytosis in apparently healthy children.
The processing of digital research material by the method of
correlation analysis made it possible to establish the presence of a correlation between shifts in individual indicators of immunological reactivity in patients with allergic rhinitis. Thus, in the period of exacerbation of the disease in children with allergic rhinitis, a direct correlation was found between an increase in the absolute number of C D 20-lymphocytes in the blood and an increase in the level of total immunoglobulin E in the blood serum (r = +0.80, p<0.01 ). At the same time, in children with allergic rhinitis in the period of exacerbation of the disease, an inverse correlation was noted between an increase in the relative number of CD 8-lymphocytes in the blood and a decrease in the values of the phagocytic index (r = -0.70, p<0.05), between an increase in the relative the number of CD 8-lymphocytes in the blood and a decrease in the values of the NCT test (r = -0.71, p<0.05).
Conclusion.
The results of our own research indicate that among the children of preschool and primary school age observed by us with persistent moderate allergic rhinitis, there were one and a half times more boys than girls. In a number of patients with allergic rhinitis, signs of food and drug allergies were revealed; in all patients, polyvalent sensitization of the body to household, epidermal and pollen allergens was recorded. The debut of allergic rhinitis in the observed patients was at the age of 4-5 years. Exacerbations of allergic rhinitis occurred year-round at intervals of 3-4 months and were associated with exposure to causally significant allergens, intercurrent infection, or ingestion of intolerable foods. In the period of exacerbation of the disease, patients were found to have emotional lability and increased motor activity, sleep disturbances and decreased appetite. All patients had a slight hoarseness and spasmodic cough, nasal congestion and difficulty in nasal breathing, itching in the nose, frequent sneezing, profuse mucous or watery discharge from the nose, and a characteristic rhinoscopic picture. In children with persistent
moderate allergic rhinitis during the period of exacerbation of the disease, there was an increase in the absolute number of lymphocytes and monocytes in the blood, pronounced eosinophilia, significant changes in the content of populations and subpopulations of lymphocytes in the blood, an increase in the content of serum immunoglobulins G and M, a pronounced increase in the content of total immunoglobulin were recorded. E in blood serum, shifts in phagocytosis. Between shifts in a number of indicators of immunity in patients with allergic rhinitis, close correlations were revealed. In the period of clinical remission in children with allergic rhinitis, there were no clinical symptoms of the disease, normalization of the rhinoscopic picture was noted, but eosinophilia and changes in a number of parameters of immunological reactivity persisted, which may be a sign of the readiness of the patient's body for an allergic reaction and exacerbation of the process when exposed to adverse environmental factors.
The presence in children with persistent allergic rhinitis of manifestations of polyvalent sensitization of the body, pronounced changes in immunological reactivity during the period of exacerbation of the disease, which persist even after the onset of clinical remission, indicate the advisability of including therapeutic measures aimed at correcting immune disorders in the complex therapy of patients. For this purpose, domestic immunomodulators of a new generation (imunofan and polyoxidonium) and ozone therapy, which have anti-inflammatory, detoxifying, antioxidant and immunomodulatory effects, can be used and have no contraindications for use.
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