Anaphylaxis after nasal provocation test with alternaria alternata extract

Background

Alternaria alternata is an ascomycete mold. It is predominantly an outdoor allergen, even though it can be found indoor, mostly derived from outdoor sources. In sensitized individuals, exposure to Alternaria alternata can exacerbate respiratory (asthma, rhinitis) and cutaneous (atopic dermatitis) symptoms. For the diagnosis of allergic rhinitis, nasal provocation test (NPT) can be used in clinical practice, since it helps to determine a correct therapy. Incidence of anaphylaxis after NPT is not known.

Case report

55 years old woman, retired school teacher, with moderate-severe persistent rhinitis since childhood. She had been receiving regular treatment with beclometasone dipropionate and an antihistaminic, with some relief of her symptoms. Frequently she required antibiotics for the treatment of bacterial sinusitis. Negative family history for atopy.

Method

Skin prick test to aeroallergens was positive only to Alternaria alternata (4 mm – positive control 7 mm). We decided to perform a NPT in order to demonstrate clinical relevance of this allergen.

Alternaria alternata extract used in this nasal provocation was provided at a concentration of 30 HEP/mL. Vital signs, peak nasal inspiratory flow and peak expiratory flow were normal. Challenge was initiated with placebo (0.9% saline solution), and after 30 minutes Alternaria dilution 1:1000 was delivered into each nostril with a spray bottle.

Results

Thirty minutes later after dilution 1:1000 had been delivered, the patient presented with severe naso-ocular symptoms and wheals in the neck. Although she had moderate dry cough, pulmonary auscultation and pulse oximetry were normal. Blood pressure, peak nasal inspiratory flow and peak expiratory flow were also within normal range. Standard treatment was administered, and the patient was admitted for inpatient observation and treatment period. After 24 hours the patient was discharged asymptomatic.

SYMPTOMS	BASAL	30 MIN AFTER 0,9% SS	30 MIN AFTER 1:1000 DILUTION
Pruritus	1	2	5
Rhinorrhea	1	1	6
Obstruction	1	1	5
Sneezing	0	0	1
TOTAL	3	4	17

           

Table 1. Nasal symptoms score test.

Conclusion

We present a patient with anaphylaxis due to Alternaria alternata extract during a NPT.  Although blood pressure remained normal, both upper respiratory tract and skin were compromised. Standard treatment was successful.