A 14-year-old boy is brought to the office due to intermittent rhinorrhea, nasal congestion, and nasal itching for the past 2 months. He has also had periodic itchy, watery eyes and an occasional daytime cough. The boy's symptoms occur usually after he plays with a neighbor's cat, and they cause the boy to be more tired than usual and have difficulty sleeping. He has had no fever, headache, weight loss, or sick contacts. The patient has atopic dermatitis and was hospitalized for bronchiolitis at age 2. He uses a topical corticosteroid ointment as needed, and his immunizations are up to date. Family history is significant for a younger brother with asthma. Vital signs are within normal limits. Physical examination shows a well-appearing boy with dark, edematous lower eyelids and pale, boggy turbinates with clear rhinorrhea. Lungs are clear to auscultation. Skin examination shows dry, scaly patches in the antecubital fossae bilaterally with associated excoriations. Which of the following is the most effective long-term strategy for relief of this patient's symptoms?
A)Avoidance of the cat
B)Intranasal cromolyn sodium
C)Intranasal decongestant
D)Oral corticosteroid
E)Second-generation antihistamine

Question

A 14-year-old boy is brought to the office due to intermittent rhinorrhea, nasal congestion, and nasal itching for the past 2 months.  He has also had periodic itchy, watery eyes and an occasional daytime cough.  The boy's symptoms occur usually after he plays with a neighbor's cat, and they cause the boy to be more tired than usual and have difficulty sleeping.  He has had no fever, headache, weight loss, or sick contacts.  The patient has atopic dermatitis and was hospitalized for bronchiolitis at age 2.  He uses a topical corticosteroid ointment as needed, and his immunizations are up to date.  Family history is significant for a younger brother with asthma.  Vital signs are within normal limits.  Physical examination shows a well-appearing boy with dark, edematous lower eyelids and pale, boggy turbinates with clear rhinorrhea.  Lungs are clear to auscultation.  Skin examination shows dry, scaly patches in the antecubital fossae bilaterally with associated excoriations.  Which of the following is the most effective long-term strategy for relief of this patient's symptoms?
A)Avoidance of the cat
B)Intranasal cromolyn sodium
C)Intranasal decongestant
D)Oral corticosteroid
E)Second-generation antihistamine

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0db_7122_8f63_b10c79772e81_MD0005_00 Allergic rhinitis is characterized by symptoms such as nasal congestion; itchy, watery eyes; clear rhinorrhea; and sneezing in response to a particular allergen. Nasal congestion can cause sleep-disturbed breathing, leading to daytime fatigue and irritability, and cough from postnasal drip. Examination often shows "allergic shiners" (dark, edematous lower eyelids) and pale, boggy turbinates, as seen in this patient. Animal dander is one of the most common identifiable allergens in patients with allergic rhinitis, and the neighbor's cat is the most likely trigger for this patient's symptoms. Allergen avoidance is the first step in management. Eliminating any exposure to the allergic trigger (eg, cat) is optimal. However, it may not always be possible to remove a family pet from the home, in which case reducing exposure can include keeping the animal outside or away from the area where the patient sleeps. In addition, minimizing drapery, carpet, and fabric-covered furniture where allergens can accumulate is beneficial, and using high-efficiency particulate air (HEPA) filters and vacuum filters helps remove allergens. If allergen avoidance is not possible or does not result in complete resolution of symptoms, intranasal corticosteroids (eg, fluticasone spray) are first-line pharmacologic therapy. (Choices B and E) Intranasal cromolyn sodium and second-generation antihistamines (eg, cetirizine) are options for the treatment of allergic rhinitis that does not resolve with allergen avoidance. However, avoiding the cat for a trial period should precede pharmacotherapy, and intranasal corticosteroids should be tried before other agents. (Choice C) Nasal decongestive sprays (eg, oxymetazoline) are not recommended for prolonged use (>3 days) as rebound congestion will result. (Choice D) Oral corticosteroids are prescribed for asthma exacerbations; however, this patient has no wheezing or nighttime cough, making an asthma exacerbation unlikely. Systemic corticosteroids also have more side effects than intranasal corticosteroids, which are preferred for allergic rhinitis not responsive to allergen avoidance. Educational objective: Allergic rhinitis is characterized by nasal congestion; itchy, watery eyes; clear rhinorrhea; and sneezing in response to an allergen. Whenever possible, avoidance of the allergen is the first step in management of allergic disorders. References: Clinical practice guideline: allergic rhinitis. (http://www.ncbi.nlm.nih.gov/pubmed/25644617)

A 14-Year-Old Boy Is Brought to the Office Due to Intermittent