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Wise et al.

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count (>10%) and pulmonary manifestations. 238,248 EGPA is often associated with the presence of p-ANCA. 247 CRSwNP is present in approximately 50% of patients. 238 Nasal pain with purulent or bloody nasal discharge, nasal crusting, or nasal septal perforation can be present but are less common than in GPA patients. 238,250 Treatment usually includes high doses of corticosteroids and immunosuppressants. 248,251 Anti-IL-5 therapy (mepolizumab) is a potential biological treatment offering clinical benefit and stability and reducing corticosteroid needs. 252 Sarcoidosis.: Sarcoidosis is a chronic multisystem disorder characterized by bilateral hilar adenopathy, pulmonary infiltration, ocular, and skin lesions. 238,253 More commonly seen in young and middle-aged adults, 254 females more frequently than males, and African Americans, 255 a prevalence of 50 per 100,000 individuals has been reported. 236 The involvement of the upper respiratory tract epithelium is infrequent 236 and nasal symptoms are nonspecific: obstruction, epistaxis, nasal pain, epiphora, and anosmia. 237 The most consistent findings are erythematous, edematous, friable, and hypertrophied mucosa in the septum and inferior turbinate. Submucosal yellow nodules representative of intramucosal granulomas may be identified in mucosal biopsies, while nasal polyps, rhinophyma, and septal perforations have also been reported. 238,256 Aggressive non-caseating granulomas can cause hard or soft palate erosions as well as septal perforations leading to saddle-nose deformity. 257,258 The diagnosis of sinonasal sarcoidosis is based on the clinical findings with either polypoid changes or characteristic yellowish submucosal nodularity. 238 Tissue for diagnosis is usually obtained by transbronchial-lung biopsy 254 or nasal biopsy, as well as from skin lesions, minor salivary glands, and lymph nodes. 238 The primary treatment for sarcoidosis is systemic steroids, chloroquine, immunosuppressants, and lung-transplantation. 237,238,256,257 The emergence of biological therapies has increased the therapeutic options to treat refractory organ-threatening sarcoidosis, with monoclonal anti-TNF (tumor necrosis factor) agents (infliximab) being the most promising. 259 Systemic lupus erythematosus.: Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect any body system. SLE predominantly affects women (10:1) with an incidence of 5.6 per 100,000 people. 260 The skin of the nose and nasal vestibule can also be involved in the skin rashes. 237 Mucosal lesions are seen in 9% to 18% of cases, with oral, nasal, and pharyngeal mucosa being commonly affected. 260 The diagnosis requires a detailed medical history, a physical examination, and laboratory tests (anti-nuclear antibody [ANA] or anti-double-stranded DNA), including a complete blood count, chemistry panel, and urinalysis. 236,261 Therapy with corticosteroids, immunomodulators (prasterone, vitamin D, hydroxychloroquine), or immunosuppressants (azathioprine, cyclophosphamide, or mycophenolate) is prescribed for symptom control, 238,262 while belimumab is a recent biological (anti-BAFF [B-cell activating factor] monoclonal antibody) to potentially treat SLE. 263 III.C.14. Rhinosinusitis— The symptoms of AR may overlap with other forms of nasal inflammation, including rhinosinusitis. It is important to differentiate between AR and rhinosinusitis to ensure the correct diagnosis and subsequent treatment can be pursued. AR may be associated with comorbid rhinosinusitis, although whether AR increases the risk of

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.