CC BY
0MODERN VIEWS ON THE CLINICAL COURSE OF ALLERGIES TO HOUSE DUST MITES AND MODERN METHODS OF THERAPY
Yuldashov I.R.
Tashkent Pediatric Medical Institute https://doi.org/10.5281/zenodo.13293061
Abstract. In recent years, there has been a sharp increase in the number of allergic diseases. The main risk factor for the development of sensitization is house dust, which accumulates in large quantities in homes and plays an important role in the development of allergic diseases such as allergic rhinitis, bronchial asthma, and atopic dermatitis. The main component of house dust is house dust mites.
The most important in the development of sensitization are Dermatophagoides pteronyssinus, Dermatophagoides farinae, Euroglyphus maynei, Lepidoglyphus destructor and Blomia tropicalis. Currently, an allergy diagnostic method using the molecular components of allergens (CR-diagnostics) is available, which allows to most accurately determine the allergen molecules involved in the development of the disease, which is important for prescribing and assessing the effectiveness of ASIT.
Keywords: allergic diseases; house dust mites; Dermatophagoides pteronyssinus; diagnostics; treatment; ASIT.
Actuality. Allergic diseases are a global health problem. Long-term epidemiological studies show a progressive increase in incidence associated with changes in the ecology of modern cities [1,3,12,16]. The population of cities spends a significant part of their lives in various rooms, in which, with the direct participation of humans, specific environmental factors are formed: air temperature and humidity, electromagnetic radiation, etc. In addition, the rooms are colonized by living organisms - house dust mites, molds and yeasts, insects etc. All of them, as a result of their vital activity, produce allergens, contact with which can lead to the development of various allergic diseases - allergic rhinitis, bronchial asthma, atopic dermatitis [2,11,25].
The main source of allergens are house dust mites, which are ubiquitous, but there are significant fluctuations in allergen levels depending on rural and urban regions of residence, in particular, in the city of Tashkent this indicator is significantly higher than other regions of Uzbekistan. In the city of Tashkent, natural and climatic conditions are expressed by frequent inversions and stagnation in the atmosphere, which contributes to the accumulation of pollutants in the ground layer of the atmosphere [17]. High dust content in the air is partly explained by the dry climate, sandy loam soils and frequent winds, which causes the widespread prevalence of allergic diseases among the population [19,23].
The source of allergic diseases (AD) can be different allergens: household, pollen, epidermal, infectious, food, medicinal, as well as various occupational sensitizers [15,21]. The most common is the so-called "household sensitization". Within the framework of household sensitization, the development of allergies to house dust plays a major role.
Etiological factors. As mentioned, the main risk factor for the development of allergic diseases is the common species of mites that produce allergens, these are Dermatophagoides
pteronyssinus and Dermatophagoides farinae. House dust, from the point of view of its antigenic composition, is multicomponent. It necessarily includes microscopic, 200 to 600 |im in size, pyroglyphide mites [8,14,26]. In addition, household dust may contain epidermal allergens (both animal and human), fungal spores, plant pollen, insect allergens (primarily cockroach allergens, fragments of chitinous shells and insect excrement), bacteria and other fragmentary organic elements [ 9,10].
The specific set of allergens differs somewhat in different rooms depending on the presence or absence of pets, mold, cockroaches and other features of the living space [18]. Moreover, in one house there may be a combination of different types of mites [27]. In rural areas, the presence of Turophagus putresceniae and Acarus siro is possible (they are especially abundant in flour, grain, and hay).
Ticks are a normal component of nature, saprophytes. If a person does not have a household allergy, then this mite is invisible to him; the human immune system does not react to the mite in any way. Mites feed on desquamated epidermis, particles of dandruff, and hair, so the highest concentration of mites is found where there is a lot of this food - in bedding (pillows, mattresses), upholstered furniture, carpets, bedside rugs, soft toys, ottomans, etc. There are especially many ticks in bed, where comfortable conditions for their life are created. Several thousand individuals are found in 1 g of mattress dust. In bed there is plentiful food (about 1 g of epidermis dies and sloughs off every day), optimal humidity and warmth.
Clinical manifestations. House dust mites are classified as inhalant allergens. Accordingly, the main manifestations of such allergies are respiratory ADs. In the genesis of respiratory allergies, mites play a leading role: about 75% of patients with respiratory AD have sensitization to household mites [22,25,29].
Ticks are both the source of the disease and the trigger of symptoms or exacerbation of the disease. According to some data, a concentration of mite allergens of 0.5 pg/g of dust causes sensitization in individuals with a genetic predisposition to atopy. A concentration of 10 mcg/g of dust (or 500 mites in 1 g of dust) provokes an attack of bronchial asthma. Although the latter values are conditional, since individual sensitivity is very variable [8,13,19].
The main manifestation of allergy to mites is allergic rhinitis or rhinitis in combination with conjunctivitis. Allergic rhinitis is the most common AD, and among all the causes of rhinitis, allergies with household sensitization are the most common. Symptoms of allergic rhinitis most often include a runny nose, usually watery, sneezing, and nasal congestion [25]. In some patients, nasal congestion is the leading symptom of the disease. In many cases, rhinitis is accompanied by itching of the eyelids, lacrimation, and sometimes pain in the eyes. There is a characteristic relationship between the appearance of symptoms and the presence of household dust. Exacerbations of the disease occur in a dusty room, when cleaning the apartment, or in contact with dusty things [28]. Indoors, patients feel much worse than outdoors (if there is no concomitant hay fever). The elimination effect is very characteristic - the disappearance of allergy symptoms when moving to another room, to another area with a significantly smaller number of household allergens [3].
In pediatric practice, the characteristic symptoms of allergic rhinitis will be "allergic salute" (regular impact on the tip of the nose with the palm of your hand, moving from bottom to top), "allergic glasses" (dark circles under the eyes), swelling of the lower eyelids, constantly open mouth, sniffing, hyperemia skin in the area of the wings of the nose.
With sensitization to mites, allergic rhinitis has a year-round course, usually persistent, less often, in the case of a mild course of the disease, intermittent. In the latter case, rhinitis manifests itself periodically: upon contact with a large amount of allergen (for example, when cleaning an apartment) or as a kind of "tail" of an acute respiratory viral infection (ARVI), when after the completion of an ARVI, household allergic rhinitis persists for a long time (up to several weeks). If an allergy in such a patient has not been previously diagnosed, then such a prolonged runny nose is mistakenly regarded as "weakness of the immune system" or a complication of acute respiratory viral infection, such as sinusitis. It should be noted that with allergic rhinitis, an x-ray of the paranasal sinuses often reveals parietal thickening of the sinus mucosa as a manifestation of allergic rhino sinusitis [11]. It is precisely such radiological data that make it possible to mistakenly diagnose an infectious rather than an allergic complication of ARVI. In this case, of course, a true infectious complication is also possible - both viral and bacterial sinusitis or sinusitis - with a classic x-ray level of fluid in the sinuses and other signs [14]. It is also necessary to keep in mind that allergic inflammation, especially long-lasting, including sluggish, causes a tendency to infection and persistence of the infectious agent. Therefore, the lack of anti-allergic treatment can also lead to secondary infection with the development of bacterial sinusitis. Thus, one of the manifestations of allergic household rhinitis, especially if not diagnosed in time, may be frequent acute respiratory viral infections [27,30,31,32]. In this case, the often practiced "restoration" or stimulation of the immune system is useless. The key to solving this problem is adequate antiallergic treatment.
Mild allergic rhinitis can only manifest itself as a runny nose after waking up, in the morning, and rare episodes of rhinitis during the day. Typically, patients do not pay attention to this, considering a morning runny nose to be a natural manifestation: "blow your nose and go to work or school." In such cases, under diagnosis of allergic rhinitis is also observed.
Allergies to ticks usually occur throughout the year. However, the year-round course of the disease has seasonal peaks of more severe allergy symptoms. The exacerbation of the disease is typical in the autumn-winter period, especially at the beginning of autumn, when a person is indoors more often, windows are opened less often, and the central heating is turned on. Heating significantly reduces the relative humidity in the house, which leads to an increase in household dust and, accordingly, inhalation allergens in the air. But the moisture of the substrate (bedding), necessary for the life of the tick, is preserved. Optimal conditions for mites are relative humidity of 75-80% and substrate (dust) humidity of 10-14% [4,5,32]. Household mites play an important role in the pathogenesis of atopic bronchial asthma. They can be the main factor shaping the disease and one of the main triggers of bronchial asthma. Symptoms of the disease are usually standard for bronchial asthma: cough, difficulty of breathing, whistling or wheezing in the chest, asthma attacks. The course of the disease is the same as in the case of allergic rhinitis, i.e. year-round with deterioration in the autumn-winter period, with a clear reaction to household dust and an elimination effect. Almost all patients with atopic bronchial asthma also have allergic rhinitis. In addition to respiratory allergies, household mites take part in the pathogenesis of skin ADs -atopic dermatitis or eczema and, much less frequently, urticaria. These diseases have a complex genesis and development mechanisms, but in some patients, especially with atopic dermatitis, Dermatophagoides mites play an important role. With an allergy to house dust mites, a cross-allergic reaction sometimes occurs due to the chitinous shell of the mite. In such cases, insect allergies (reaction to chitin of cockroaches), food allergies (to chitin-containing crabs, crayfish,
shrimp, lobsters) are detected. Food allergies may be of particular importance for patients with cutaneous AD.
Diagnostic tests and treatment. In vivo and in vitro diagnostic methods are widely used to diagnose sensitization to house dust mite allergens. Among in vivo diagnostic methods, an important place is occupied by the skin testing method, which detects immediate type reactions in the case of IgE-dependent allergic reactions [4, 5, 8]. In case of discrepancy between skin testing results and medical history, provocative tests are recommended [8,30,31].
In vitro diagnostics. The study of the levels of total and specific IgE antibodies in the diagnosis of allergic diseases has been used since 1967. To determine the levels of specific IgE antibodies, the quality of the reagents used is of great importance; Standardized extracts should be used whenever possible. Measurement of specific IgE antibody levels is independent of medication use or the presence of skin diseases [26].
When using standardized allergens, the results obtained from the determination of allergen-specific IgE antibodies closely correlate with data from skin testing and nasal provocative tests [10, 29].
Component diagnostics (Component resolved diagnostic, CRD, CR-diagnostics). With the introduction of molecular biotechnologies, molecular identification of many important allergens involved in the development of the disease has become possible. For most allergens (such as tree pollen, grass pollen, mites, animal dander, mold, etc.), the development of recombinant allergen panels has become possible. In addition, it has been proven that the use of recombinant allergens, in addition to allergenic extracts, significantly increases the sensitivity of diagnostic techniques, since recombinant allergens contain a large number of epitopes of natural allergens. This research method became possible after the release of the Immuno Cap ISAC diagnostic test system developed by Phadia AB (Uppsala, Sweden). This diagnostic technique allows the measurement of levels of specific IgE antibodies to individual allergenic molecules recombinant or isolated from natural sources and provides insight into the sensitizing profile of patients with atopy [7, 18, 20, 24].
Component diagnosis in the case of tick allergies uses the determination of specific IgE antibodies to molecules of recombinant and purified allergens (nDer p 1, nDer f 1, nDer p 2, rDer f 2, rDer p 10, rEur m 2). This helps in identifying major allergens and excluding cross-reactivity with allergens such as mite tropomyosin. In the case of pyro-glyphide mites, CR diagnostics helps to identify groups of patients who do not have sensitization to groups 1 and 2 of allergens, as well as those who have polyvalent sensitization. Pittner et al. showed that patients sensitized to Der p 1 and 2, as well as to a large number of other allergens, in comparison with patients who have specific IgE antibodies only to allergens of groups 1 and 2, show a less positive response in the case of allergen testing [20]. Treatment of allergies to house dust mites must be carried out in several directions.
1. Maximum possible elimination measures.
2. Drug treatment. It is carried out in accordance with clinical recommendations for each disease (allergic rhinitis, bronchial asthma, atopic dermatitis). The following is used as antiallergic therapy (mainly symptomatic):
- antihistamines (for patients with bronchial asthma, only second-generation antihistamines are used and only in special situations, for example, before contact with a significant amount of household dust);
- intranasal glucocorticosteroid drugs, which are most effective in the treatment of allergic rhinitis;
- mast cell membrane stabilizers: intranasal cromoglycates, ketotifen. Their effectiveness in allergic rhinitis is significantly lower than that of glucocorticosteroids, but in pediatric practice, cromoglycates can be quite effective;
- anti-leukotriene drugs used for allergic rhinitis, bronchial asthma;
- intranasal drugs with a local barrier effect (with local intranasal use, they create a mechanical barrier between the mucous membrane and allergens coming from the external environment).
3. Allergen-specific immunotherapy (ASIT). This is the only pathogenetic treatment method that allows to change the natural development of AD, prevent the development of bronchial asthma and sensitization to new allergens, and lead to allergen-specific immune tolerance. The method consists of introducing into the patient's body increasing doses of the allergen responsible for the clinical manifestations of the disease in patient.
The allergen is administered by injection (only in the allergology office by specially trained personnel) or sublingually according to a certain technique. The total duration of the effect of ASIT is 3-5 years. The effectiveness of the method is about 85%; effectiveness is higher in cases where treatment is started in the early stages of the disease.
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