Professional Documents
Culture Documents
10.5005/jp-journals-10013-1209
Bhaskar Thakkar et al
ORIGINAL ARTICLE
Thakkar,
2 Ashish
Katarkar,
3 Datt
Modh,
ABSTRACT
4 Anil
Jain,
5 Pankaj
Shah,
6 Krupal
Joshi
INTRODUCTION
Allergic rhinitis is a common condition affecting 5 to 40% Allergic rh initis is a major atopic condition. A llergic
of general population and its prevalence is increasing. It is rhi nitis is a common health problem caused by inflam a chronic condition characterized by inflammation of nasal
mator y reaction after allergen exposure and associated
mucosa. As per recent studies, there is an association between
with an immunoglobulin E (IgE) mediated immune
ser um vitamin D levels and allergic rhinitis status. Vitamin D has
response against allergen. It is the most common form
major role in the regulation of calcium metabolism. In addition
of the noninfectious rhinitis. It is not a life-threateni ng
to this, it also has a number of immunol ogica l effects an d takes
part in immunomodulation, which can significantly affectcondition
the
but in most cases it interferes with the patients
outcome of allergic responses like in allergic rhinitis. persona l li fe and imposes a substantia l burden on public
allergic
Materials and met hods:
Vitamin D level s wer e assessed
in rhinitis, i ncluding antihi stam ines and topical
corticosteroids.
Yet, there is a2 need for new treatment
23 patients with allergic rhinitis diagnosed clinically by allergic
particularly aiming at new targets and associated
rhinitis and its impact on asthma 2008 criteria and results options,
were
compar ed with vitamin D status in the nor mal population of
with reduced side effects. The prevalence varies among
same region.
countries, probably because of geographic and aero-
allergen differences.
Allergic rhiniti3-6s affects between
Re sults: The levels of serum vit amin D levels were signifi c ant ly
low in the pati ents of aller gic rhinitis.
10 and 30% of all adults and as many as 40% of children.
India,
Conclusion: Measuri ng of serum levels of vitamin D In
could
be allergic rhinitis (AR) is considered to be a trivial
considered in the routine assessment of pati ents with allergicdisease, despite the fact that symptoms of rhinitis were
present in 75% of children and 80% of asthmatic adults.7
rhinitis.
8
Key words: Allergic rhinitis, Vitamin D deficiency, Cal citriol. One-sixth of Canadians suffer from this disorder.
Nil
College
Corresponding
Department
Medical
Phone:
Department
Department
8866148963,
and
College
of
Hospital,
ofENT
ofAuthor:
and
Community
ENT
and
e-mail:
Hospital,
Surendra
and
Head
Head
ashishkatarkar@gmail.com
Medicine,
Surendra
and
Nagar,
and
Neck
Neck
Ashish
Gujarat,
Nagar,
Surgery,
CU
Surgery,
Katarkar,
Shah
India
Gujarat,
CU
Medical
CU
Shah
Professor
Shah
India
AIJCR
Deficiency of Vitamin D in Allergic Rhinitis: A Possible Factor in Multifactorial Disease
Table 1:
Table 2:
14
Score 0 to 3
Rhinorrhea 0 to 3
Male 11 47.82
Obstruction 0 to 3
Female 12 52.18
Sneezing 0 to 3
Total 23 100
Sex distribution
Itching 0 to 3
Anosmia 0 to 3
TableDistribution
4:
of patients according to
symptoms score
TNSS Out of 15
0: Absent; 1: Mild; 2: Moderate; 3: Severe
Table 3:
Age distribution
7 to 10 13 (56.52%)
3 to 6 1 (4.34%)
20-24 2 8.69
0 to 2 0
25-29 4 17.39
Bhaskar Thakkar et al
Table 5:
15
Table
Correlation
6:
of symptoms severity with
vitamin D levels
Total nasal
symptom score No. of patients
Total 23
7 to 10 11 (52.38%) 18.15
3 to 6 1 (4.76%) 26.3
Mean Vit. D
levels in ng/ml
0 to 2 0 0
rhinitis or other allergic disease or any other illness that
can affect serum levels of vitamin D, we found there was
This regulatory effect has a downstream impact
significant difference. Mean serum vitami n D level of the
on the levels of circulating chemokines and cytokines.
normal individuals 34.94 15.65 ng/ml, while it was 19.52
Th1 cells secrete interferon gamma (IFN ), interleukin
7.35 ng/ml i n 23 patients of allergic rhinitis bei ng low
(IL)-2, IL-12, and tumor necrosi s factor alpha (TNFa),
with statistically signi ficant at p-value of 0.00059 (<0.05)
all of which augment the cell-mediated defense agai nst
suggesting deficiency in patients of allergic rhinitis.
intracellular pathogens. Th2 cells express IL-4, IL-5 and
Moreover, the deficiency was more pronounced i n
IL-13, which further propagate the Th2 response. These
the patients having severe allergic rhinitis as shown in
Th2-derived cytokines modulate the immune response
Table 6, the patients with TNSS > 11 were having agai
meannst parasites and a re also associated with the regulavitamin D level 16.88 ng/ml.
tion of atopy and asthma. 24,25
Vitamin D exerts suppressive effect on the expression
DISCUSSION
of IL-2 and IFN in a VDR-regulated mechanism. The suppression of IL-2 production, in turn, inh ibits T-cel l proliIn allergic rhinitis symptoms arise as a result of local
inflammation induced by aeroallergens such as pollens,
feration. Addition of exogenous IL-2 can rescue T-cells
VitaminD.
D1
molds, anima l dander and house dust mites. The immu ne from the anti proliferative effects of vitamin
blocks the induction of Th1 cytokines, especially IFN ,
response involves the release of inflammatory mediators
while
and the activation and recruitment of di fferent inflam
- simultaneously enhancing Th2 responses through
26,27
the enhancement of IL-4
Overall,
production.
vitamin
D
mator y cell s to the nasal mucosa. 16 I nfilt ration of inflam mator y cells is evident i n both seasonal and perennialdecreases cell-mediated immune responses. This supform, although the magnitude of these cellular changes pressive effect on humoral immunity is facilitated
th rough the effect of vitamin D3 on APC. In APCs, calciis somehow different in seasonal and peren nial allergic
triol inhibits the production of IL-12, a cytokine that norrhinitis. 17
mally enhances the Th1
In response.
effect, vitamin27D
A characteristic feature of allergic inflammation
is local accumulation of inflam matory cells i ncludingacts as a physiologic brake on humoral immunity.
Similarly, vitamin D also inhibits the in nate i mmune
T lymphocytes, mast cells, eosi nophils, basophils and
system. Vitamin D i nhibit the differentiation, maturation,
neutrophils. 18 Release of various mediators from these
and im20mune-stimulating ability of dendritic cells by
cells is responsible for the symptoms of allergic rhinitis.
downregulating the expression of MHC class II moleAccumulation of additional i nflammatory cells such as
Immatu recudendritic
les.20 cells promote T-cell tolerance,
eosinophils and T cells occurs in response to various
whereas mature dendritic cell s activate naive T cells.
chemokines and cytokines.
Physiologic levels of vitamin D inhibit the maturation of
dendritic cells and maintain an immature a nd tolerogenic
Vitamin D and Immunomodulation
phenotype with inhibition of activation markers such as
Vitamin D has immunomodulatory steroid hormoneMHC class II, CD40, CD80 and CD86 and up regulation
properties and directly affects dendritic cell, monocyte,
of inh ibitory molecules.
21,22 (Fig. 1:
macrophage,
B
cell,
and
T
cell
functions
114
vitamin
bolizing
immune
direct
dihydroxyvitamin
results
bling
The
calcitriol
targets
in
D
vitamin
enzymes
system
effects
a five-fold
oftothe
like
Dregulate
on
are
D3.
receptor
activated
Th1
immune
expressed
increase
Indeed,
and
at(VDR)
least
form
Th2
system).
activation
in
by102
cells.
of
VDR
and
several
vitamin
identified
vitamin
They
of
expression,
cells
CD4+
are
D,D
of
genes.
1,25thecheck
may
meta-The
T
the
is
level
cells
penaskewe
roliferation
have
enhance
of the
on
net
da23Vitamin
the
toward
suppressive
response
nasal
sof
suppression
immune
IL-10
T mucosa,
regulator
Da concurrently
production
isTh2
aresponse.
effect
decrease
of
response
potentially
cel
the
on
lsin
Th1
The
which
suppresses
in
inflam
these
Th1
with
response.
immune
Thus,
influencing
act
dendritic
responses
mation
a as
vitami
significant
IL-12
response
a further
at
cells.
nand
the
D
19
26,27
28
AIJCR
Deficiency of Vitamin D in Allergic Rhinitis: A Possible Factor in Multifactorial Disease
development and propagation of CRS. Interestingly,could be used to help determine the disease severity and
vitamin D has also been shown to have a stimulatory
possibly even treatment.
effect on monocytes in vitro , suggesting a complex role
CONCLUSION
in immune homeostasis rather than a purely suppressive
Bhaskar Thakkar et al
P, Morales-Torres J. IOF Commit tee of Scientific Advisors
(CSA) Nutrition Working Group. Global vitamin D status
and determinants of hypovitaminosis D. Osteoporosis Int
2009 Nov;20(11):1807-1820.
10. Schauber J, Gallo RL. Vitamin D deficiency and asthma: not
a strong link yet. J Allergy Clin Immunol 2008 Mar;121(3):
782-783.
11. Litonjua AA, Weiss ST. Is vitamin D deficiency to blame
for the asthma epidemic? J Allergy Clin Immunol 2007
Nov;120 (5):10 31-1035.
12. Clifford RL, Knox AJ. Vitamin D: a new treatment for airway
remodelling in asthma? Br J Pharmacol 2009 Nov;158(6):
1426 -1428 .
13. Sidbury R, Sullivan AF, Thadhani RI, Camargo CA Jr.
Randomized controlled trial of vitamin D supplementation
for winter-related atopic dermatitis in Boston: a pilot study.
Br J Dermatol 2008 Jul;159(1):245-247.
14. zgr A, Arslanoglu S, Etit D, Demiray U, nal HK.
Comparison of nasal cytolog y and symptom scores in
pat ients with seasonal allergic rhinitis, before and after
treatment. J Laryngol Otol 2011 Oct;125(10):1028-1032.
15. Heaney RP. Vitamin D deplet ion and effect ive calcium
absorption. J Bone Min Res 2003 Jul;18(7):1342.
16. Dykewicz MS, Fineman S, Skoner DP, Nicklas R, Lee R,
Blessing-Moore J, Li JT, Bernstein IL, Berger W, Spector S, e t al.
Diag nosis and management of rhinitis: complete guidelines
of the Joint Task Force on Practice Parameters in Allergy,
Asth ma and Immunology. American Academy of Allergy,
Asth ma, and Immunology. An n Allergy Asthma I mmunol
1998 Nov;81(5 Pt 2):478-518.
17. Howarth PH. Eosinophils and rhinitis. Clin Exp Allergy
20 05;5:5 5-63 .
18. Varney VA, Jacobson MR, Sudderick RM, Robinson DS,
Iran i AM, Schwartz LB, Mackay IS, Kay AB, Durham SR.
Immunohistology of the nasal mucosa following allergeninduced rhinitis: Identification of activated T lymphocytes,
eosinophils, and neutroph ils. Am Rev Respir Dis 1992 Jul;
146(1):170-176 .
19. Mora JR, Iwata M, von Andrian UH. Vitamin effects on the
immune system: vitamins A and D take centre stage. Nat
Rev Immunol 2008 Sep;8(9):685-698.
20. Chanda R, Aggarwal AK, Kohli GS, Jaswal TS, Gupta KB.
Comparative study of nasal smear and biopsy in patients
of allergic rhinitis. Indian J Allergy Asthma Immunol 2002;
16(1):27-31.
21. Mulligan JK, Bleier BS, OConnell B, Mulligan RM, Wagner C,
Schlosser RJ. Vitamin D3 correlates inversely with systemic
dendritic cell numbers and bone erosion in chronic rh inosinusitis with nasal polyps and allergic fungal rh inosinusitis.
Clin Exp Immunol 2011 Jun;164(3):312-320.
22. Wolff AE, Jones AN, Han sen KE. Vitamin D and musculo-
116
922-932.
24. Penna G, Roncari A, Amuchastegui S, Daniel KC, Berti E,
Colonna M, Adorini L. Expression of the inhibitory receptor ILT3 on dendritic cells is dispensable for induction of
CD4+Foxp3+ regulatory T cells by 1,25-dihydroxyvitamin
D3. Blood 2005 Nov 15;106(10):3490-3497.
on the immune system: modulat ion of innate and autoimmunity. J Mol Med (Berl) 2010 May;88(5):441- 450.