European Archives of Oto-Rhino-Laryngology

, Volume 260, Issue 7, pp 390–394

Clinical, genetic and immunologic analysis of a family affected by ozena

Authors

  • Lucia Medina
    • Department of OtorhinolaryngologyUniversity of Pavia, I.R.C.C.S. Policlinico S. Matteo
    • Department of OtorhinolaryngologyUniversity of Pavia, I.R.C.C.S. Policlinico S. Matteo
  • Giulia Bertino
    • Department of OtorhinolaryngologyUniversity of Pavia, I.R.C.C.S. Policlinico S. Matteo
  • Carlo Maurizio Montecucco
    • Department of RheumatologyUniversity of Pavia, I.R.C.C.S. Policlinico S. Matteo
  • Cesare Danesino
    • Department of Human and Inherited PathologyUniversity of Pavia, I.R.C.C.S. Policlinico S. Matteo
  • Miryam Martinetti
    • Department of ImmunohematologyI.R.C.C.S. Policlinico S. Matteo
  • Eugenio Mira
    • Department of OtorhinolaryngologyUniversity of Pavia, I.R.C.C.S. Policlinico S. Matteo
Rhinology

DOI: 10.1007/s00405-002-0571-x

Cite this article as:
Medina, L., Benazzo, M., Bertino, G. et al. Eur Arch Otorhinolaryngol (2003) 260: 390. doi:10.1007/s00405-002-0571-x

Abstract

Primary atrophic rhinitis is a chronic inflammation of the nasal mucosa characterized by atrophy of the mucous and bony tissue of the turbinates and by a thick, dense secretion, which quickly forms a characteristically fetid-smelling, greenish crust. We report the results of the clinical, genetic and immunologic investigations performed on eight subjects (three with ozena and five asymptomatic), members of the same familial group. The presence of the disease in the family fits well with dominant inheritance. All the culture specimens from the patients affected by ozena were positive for Klebsiella ozaenae, and one of them was also positive for Pseudomonas aeruginosa. All the three patients with ozena and two of the five apparently unaffected family members were positive for antinuclear antibodies. Immunoblotting showed a reactivity to a 50-kD protein, which was not identified by the common, recognized nuclear autoantigens. This was present in one of the three patients and three of the five other family members. Positivity for IgG-class anticardiolipins was correlated with disease manifestation in that it was found in two of the three patients and only in one of the five asymptomatic family members. The hypothesis of a genetic factor that could drive the chronicity of the inflammatory pattern of a pre-existing infectious nasal disease is suggested.

Keywords

Atrophic rhinitisInheritanceImmunologyHistopathologyTreatment

Introduction

Primary atrophic rhinitis, or ozena, first described by Fraenkel in 1876 [1], is a progressive chronic nasal disease characterized by mucosal atrophy with resorption of the underlyng bone, formation of a thick and greenish crust and a distinct fetid odor.

Patients were diagnosed with primary atrophic rhinitis if their condition developed in a previously healthy nose and secondary atrophic rhinitis if their condition developed after sinonasal surgery, trauma, radiation exposure or chronic granulomatous disease [2].

The term "ozena" is a frequently used synonym of Greek derivation, meaning "stench." It is a rare disease, accounting for 0.3–7.8% of ENT diseases. It predominantly affects women (3:1) aged between 15 and 35 years and occurs more frequently in races of Oriental origin than in white-skinned populations [1]. The patient may present with nasal obstruction, epistaxis, anosmia, headache or, infrequently, pulmonary complications such as lung abscess. The strong, permeating, offensive odor may dominate the clinical presentation, and the extensive formation of green crusts with atrophy of the turbinal structures may be seen. The condition is also usually accompanied by nasopharyngitis, oropharyngitis and laryngitis sicca.

The etiopathogenesis of ozena is very poorly understood, although a variety of theories have been suggested, such as the microbial theory [3, 4, 5], the endocrine theory [3, 6, 7], the theory of imbalance in the autonomic nervous system, with a predominance of the sympathetic tone [8], the autoimmune theory [9, 10], the theory of inadequate iron and vitamin A intake [7, 11] and the congenital theory [12]. Some authors have noted an increased frequency within the same family [12, 13, 14, 15, 16], suggesting a possible autosomic dominant inheritance [6, 15, 17].

Three patients affected by primary atrophic rhinitis, who were members of the same family, recently came to be examined by us. We submitted the three patients and all the family members we were able to find to a series of immunologic, bacteriologic and genetic investigations in order to assess the importance of the constitutional familial or genetic factors in the etiopathogenesis of ozena.

Materials and methods

The family tree is illustrated in Fig. 1, and the case histories are summarized in Table 1. Three out of the five members affected by primary atrophic rhinits (CA, CG, AB) and five asymptomatic relatives (BM, CAL, CD, AR, AG) were examined. All the others members (affected or not affected) were not examined, because they lived far away or refused the visit. Their health status was derived from the case histories of the members of the study.
Fig. 1.

The family tree. The arrow shows the subject (10) we first examined

Table 1.

Clinical characteristics of the family members. The investigated subjects are indicated by their initials

Patient

Sex

Age

Diagnosis

I 1

M

86

Dead; thought to be normal

I 2

F

85

Dead; thought to be normal

II 1

F

65

Not examined; thought to be normal

II 2

M

65

Not examined; thought to be normal

II 3

F

62

Atrophic rhinitis; not examined

II 4

M

62

Not examined; thought to be normal

II 5 (CA)

M

61

Atrophic rhinitis with marked secretions and crusts (fetid smelling), frontal headache, hyposmia

II 6 (BM)

F

58

Normal

III 1

M

44

Not examined; thought to be normal

III 2

F

43

Not examined; thought to be normal

III 3

M

40

Not examined; atrophic rhinitis

III 4

F

38

Not examined; thought to be normal

III 5

M

37

Not examined; thought to be normal

III 6

F

36

Not examined; thought to be normal

III 7 (CAL)

F

36

Normal

III 8 (CD)

M

35

Normal

III 9 (AR)

M

34

Normal

III 10 (CG)

F

28

Atrophic rhinitis without significant symptoms

III 11

M

27

Not examined; thought to be normal

IV 1

M

20

Not examined; thought to be normal

IV 2

M

18

Not examined; thought to be normal

IV 3

M

8

Not examined; thought to be normal

IV 4

M

5

Not examined; thought to be normal

IV 5 (AB)

F

3

Atrophic rhinitis with marked secretions and crusts (fetid smelling), frontal headache, hyposmia

IV 6 (AG)

M

2

Normal

None of the eight patients examined had occupational or environmental risk factors. The investigations we performed on the three patients and the five relatives are summarized in Table 2. All the members were advised of the purpose of the study, and an informed consent was taken before the investigation. It was possible to perform nasal biopsy only in one of the eight subjects because the others refused the procedure. Nasal endoscopy was carried out with a Storz rigid 30° fiber-optic endoscope, diameter 2.7 mm, connected to a TRICAM DG Vision digital video camera and a Panasonic monitor. The nasal swab was taken under endoscopic observation from the tail of the inferior turbinate after accurate removal of secretions and crusts from the nasal fossae. Biopsy specimens of the nasal mucosa were taken, always under endoscopic observation, from the anterior nasal septum and the body of the middle turbinate. High resolution computerized tomography (CT) of the facial skeleton was carried out using slices of 1 mm in coronal and axial projections. No contrast agents were used. We preferred not to perform CT scans on the healthy members of the family because the endoscopic findings were normal.
Table 2.

Investigations performed on the eight subjects

Patient

Nasal endoscopy

Nasal swab

Nasal biopsy

CT

Immunological profile

HLA

Chromosomic map

CA

·

·

·

·

·

CG

·

·

·

·

·

·

·

AB

·

·

·

·

·

BM

·

·

·

·

CAL

·

·

·

·

CD

·

·

·

·

AR

·

·

·

·

AG

·

·

·

·

The antibody profile was carried out on the sera of patients and family members using the following methods.
  1. 1.

    Indirect immunofluorescence on Hep-2 cells (ARNIKA, Milan) was carried out for the identification of antinuclear antibodies (ANA test); on sections of rat stomach, liver, and kidney for identification of anti-smooth muscle antibodies (ASMA), anti-mitochondrial antibodies (AMA) and anti-gastric parietal cell antibodies (AGPCA); on human skin for detection of anti-keratin antibodies (AKA) and on human peripheral blood granulocytes to look for anti-neutrophilic cytoplasm antibodies (ANCA) as described by Montecucco et al. [18].

     
  2. 2.

    Solid phase immunoassay was carried out using a commercially available kit to test for the presence of and to measure the levels of anti-proteinase 3 (Anti PR3) and anti-myeloperoxidase antibodies (Anti MPO) using the Gharavi's procedure [19], slightly modified according to Montecucco et al. [20], for the presence and titer of the antibodies anti-cardiolipin (ACL) and anti-β2 glycoprotein I (GPI) [21].

     
  3. 3.

    Double immunodiffusion on rabbit thymus and primate spleen and immunoblotting (IB) on Hep-2 cell line extracts (ARNIKA, Milan) were carried out to investigate antibodies against soluble nuclear antigens (ENA) and other nuclear antigens, as described by Montecucco et al. [22].

     

HLA typing was carried out using a complement-dependent lymphotoxicity test.

Chromosome mapping was performed on samples of peripheral blood using routine techniques for staining the G and Q bands at the 550-band level.

The three patients affected by primary atrophic rhinitis were treated for 3 months with Ceftriaxone 500 mg (AB) and 1 g (CA and CG) i.m. 1/day for 6 days a month; oral vitamins A and E once a day; saline solution nasal lavage twice a day; nasal applications of 3% Gomenol oil twice a day for 10 days a month and alcaline water steam inhalations in the evening.

Results

The expression of the symptoms in the patients affected by primary atrophic rhinitis was varied. Indeed, while CG complained of slightly nasal obstruction and scarce secretions, CA and AB had substantial nasal obstruction and characteristically fetid crusts, which could be smelled even at a distance, frontal headache and hyposmia.

The findings of the endoscopic examinations carried out in the three patients with primary atrophic rhinitis before treatment were slightly hyperemic mucosa of the nasal fossae and widespread or thick and swaged yellow-greenish crusts (Fig. 2), which smelled extremely unpleasant. The endoscopic findings of the other members of the family were essentially normal. The CT scan of the facial skeleton showed neither cranio-facial dysmorphisms, nor particular alterations of the osseus components of the paranasal sinuses.
Fig. 2.

Endoscopic view of the nasal fossa of patient CAL. Note the presence of crusts and thick secretions

All the culture specimens from the patients affected by ozena were positive for Klebsiella ozaenae, while those of CA were also positive for Pseudomonas aeruginosa. These bacteria were absent in the nasal swabs of the unaffected relatives. The nasal mucosa biopsy specimen taken from CG revealed focal squamous cell metaplasia of the epithelial layer with subepithelial inflammatory granulocytic and lymphocytic infiltration.

The results of the immunological investigations are summarized in Table 3. All three patients with ozena and two of the five apparently unaffected family members were positive for ANA at a titer of <1:160. It was particularly intriguing that IB showed a reactivity to a 50-kD protein that was not identified by the common, recognized nuclear autoantigens. This positivity was not, however, associated with the manifestation of ozena, since it was present in one of the three patients and three of the five other family members. Positivity for IgG-class anticardiolipins was, on the other hand, better correlated with disease manifestation in that it was found in two of the three patients and only in one of the five asymptomatic family members. In none of the cases were the ACL antibodies reactive against β2-GPI. HLA typing carried out on both family groups did not demonstrate any correlation between the disease and genes in the HLA region (Fig.3). The chromosome map of CG was that of a normal female karyotype.
Table 3.

Immunologic profile of the eight subjects ( ANA antinuclear antibodies; ENA antisoluble nuclear antigens; ACL anticardiolipin antibodies; GPI glicoprotein I; ANCA antineutrophilic cytoplasm antibodies; MPO myeloperoxidase; PR3proteinase 3; AMA antimitochondrial antibodies; AGPCA antigastric parietal cell antibodies; ASMA antismooth muscle antibodies; AKA antihuman keratin antibodies; MM myocardic muscle)

Patient

ANA

ENA

ACL

Anti β2–GPI

ANCA

Anti MPO

Anti PR3

ASMA

AMA

AGPCA

IB

AKA

CA

1:160 speckled

28 IgG, negative IgM

Negative IgG/IgM

CG

1:80 speckled

Negative IgG/IgM

Doubt

+ (MM)

50 kD band

AB

1:80 speckled

15 IgG, negative IgM

Negative IgG/IgM

Doubt

BM

1:80 speckled

Negative IgG/IgM

+ (MM and vessels)

50 kD band

CAL

Negative IgG/IgM

CD

1:80 speckled

Negative IgG/IgM

50 kD and 58 kD bands

AR

42 IgG, negative IgM

Negative IgG/IgM

50 kD band

AG

Negative IgG/IgM

Fig. 3.

HLA haplotypic segregation of the members examined

The patients' symptoms improved significantly during and after treatment. In particular, 3 months after the end of the therapy CG was free of disease, while CA and AB demonstrated a clear reduction in secretions and crusts.

Discussion

Nowadays, the hypothesis of the existence of a hereditary factor that can influence the outbreak of ozenatous atrophic rhinitis has certainly been confirmed. In 1966, Girgis [12] was the first who reported the existence of this disease in two identical female twins. Since then, other authors [13, 14, 16, 23] have observed the existence of a significant incidence of the disease among the members of a same familial group, so that the hypothesis that ozena may be an autosomal-dominant, genetically transmitted disease with a wide variation in clinical expression within the same family has been stated [15]. The results that emerged from the analysis of our family tree confirmed this inheritance, and the clinical-anamnestic investigation revealed the existence of different expressions of the disease in the three patients.

Nevertheless, the phenotypic heterogeneity of the disease and the occurrence of sporadic cases leave open the hypothesis that there is an underlying immunogenetic heterogeneity. In fact, the haplotypic HLA segregation we carried out on three generations seems to exclude a linkage between the disease and genes in the major histocompatibility complex (MHC).

Sero-immunological analyses revealed some interesting and original data without providing proof, however, of the real involvement of the autoimmune system in the pathogenesis of ozena. In fact, positivity for ANA cannot be considered specific for autoimmune diseases; it only reflects the role of environmental factors, particularly chronic infections, as well as genetic factors [24]. This fact may, therefore, explain the positivity found in our chronically infected patients and apparently unaffected family members.

A similar discussion can be applied to the 50-kD antinuclear protein reactivity noted during immunoblotting, which seems more associated with a genetic or familial factor than the development of the disease. However, this is to our knowledge the first report of specific antibodies in patients and relatives of patients with ozena and the finding, if confirmed in further studies in other patients, is of undoubted interest.

As far as the anticardiolipin antibodies are concerned, it should be remembered that these can appear after an infection. In this case, they are usually only temporarily present and do not react against β2-GPI [25]. Positivity in our ozena patients, although significant, was limited to anticardiolipin and disappeared by the time of the second evaluation 3 months after the end of antibiotic treatment.

The results of the microbiological investigation are particularly interesting, in that the hypothesis of a microbial pathogenesis seems to be supported. Indeed, Klebsiella ozaenae was found in all three patients affected by ozena, as well as Pseudomonas aeruginosa in one case.

The antimicrobic treatment resulted in a clear improvement of the nasal stenosis and a reduction of secretions in all three patients.

Regarding the data relating to the morphologic study of the facial structure, our results differ from those in the literature in which there are reports of reduced pneumatization of the paranasal sinuses, in particular of the maxillary and ethmoid sinuses, with thickening of the bony walls [26, 27, 28, 29]. We found no decrease in pneumatization in our three patients with ozena, nor indeed any ventilatory disorder as a result of a blocked ostio-meatal complex, thought to be directly or indirectly responsible for the primary atrophic rhinitis [27].

The remarkable fact that one of our patients (AB) affected by primary atrophic rhinitis was only a 3 1/2-year-old child leads us to believe that the theory of an endocrine pathogenesis is not probable. Some authors [3, 6, 7] consider, in fact, that a local vasomotor imbalance caused by the increase in the production of female sex hormones during puberty and pregnancy is responsible, directly or indirectly, for the disease.

Conclusions

Primary atrophic rhinitis undoubtedly has a multifactorial origin. A genetic predisposition, maybe inherited by a dominant autosomic modality, could favor the outbreak, in the presence of particular infectious diseases of the nasal cavities, of autoantibodies responsible for the chronicity of the inflammatory nasal process and of the histopathologic changes of the nasal mucosa in the ozenatous patient.

Our study excluded that the putative gene for the disease is located in the MHC, while the 50-kD antinuclear protein reactivity noted during immunoblotting seems more associated with a genetic or familial factor that could cause a predisposition to the genesis of primary atrophic rhinitis. This finding, if confirmed in further studies in other patients, could be of undoubted interest for the understanding of the etiopathogenesis of ozena.

Copyright information

© Springer-Verlag 2003