A 28-year-old woman comes to the office due to persistent nasal congestion and stuffiness. The patient has a constant sensation of dripping in the back of her throat and states that food has tasted bland to her recently. A year ago, she came to the emergency department due to severe wheezing after taking naproxen for menstrual cramping. The patient has no history of head trauma. Family history is significant for asthma in her sister. She does not smoke cigarettes but occasionally smokes marijuana. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 28-year-old woman comes to the office due to persistent nasal congestion and stuffiness.  The patient has a constant sensation of dripping in the back of her throat and states that food has tasted bland to her recently.  A year ago, she came to the emergency department due to severe wheezing after taking naproxen for menstrual cramping.  The patient has no history of head trauma.  Family history is significant for asthma in her sister.  She does not smoke cigarettes but occasionally smokes marijuana.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

Explanation: This patient has persistent nasal symptoms and previously had a severe wheezing reaction after taking naproxen, a nonsteroidal anti-inflammatory drug (NSAID). This presentation is consistent with aspirin-exacerbated respiratory disease (AERD), the clinical triad of: asthma (often severe and presenting in adulthood). bronchospasm or nasal congestion following the ingestion of aspirin or NSAIDs. chronic rhinosinusitis with nasal polyposis. This patient's current symptoms of bland-tasting food (likely due to anosmia) and recurrent nasal discharge/congestion are typical in patients with nasal polyps, which are identified on nasal examination as bilateral, gray, glistening mucoid masses. AERD is classified as a pseudoallergy because it is not mediated by IgE. Although the pathophysiology is not fully elucidated, it seems to be related to overproduction of leukotrienes. Exposure to NSAIDs leads to acute reactions. In addition to typical management of asthma (eg, inhalers) and chronic rhinosinusitis (eg, intranasal saline and glucocorticoids), leukotriene-modifying agents are often prescribed for patients with AERD. AERD is typically a clinical diagnosis but can be confirmed with an aspirin challenge. Aspirin desensitization is used for patients with worsening disease or those who require aspirin or NSAID therapy for comorbid conditions (eg, arthritis, coronary artery disease). (Choices A and B) Allergic rhinitis and allergic fungal rhinosinusitis can both cause all the nasal symptoms this patient is experiencing. However, nasal symptoms in combination with a respiratory reaction to an NSAID is characteristic of AERD. (Choice D) Juvenile nasal angiofibroma is a rare, benign tumor of the nasopharynx that can cause nasal obstruction and nasal drainage but also usually results in epistaxis. In addition, it occurs almost exclusively in teenage boys. (Choice E) Patients with a perforated nasal septum often have nasal congestion with excess crusting. They may also have noisy breathing (typically a whistling noise on inspiration). However, patients usually have bleeding and typical risk factors (eg, nasal surgery, cocaine use) and do not have exacerbations after using NSAIDs. (Choice F) Pyogenic granulomas are benign vascular tumors that can occur on the nasal septum and cause congestion. However, bleeding is typically prominent because they are very friable, and there is no association with NSAID use. Educational objective: Aspirin-exacerbated respiratory disease is a clinical condition defined by the triad of asthma, bronchospasm or nasal congestion following the ingestion of aspirin or nonsteroidal anti-inflammatory drugs, and chronic rhinosinusitis with nasal polyposis. References: Revision rates after endoscopic sinus surgery: a recurrence analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21510141) Pathogenesis of aspirin-exacerbated respiratory disease and reactions. (http://www.ncbi.nlm.nih.gov/pubmed/23639708)

A 28-Year-Old Woman Comes to the Office Due to Persistent