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Nonallergic rhinitis with eosinophilia syndrome


Nonallergic rhinitis with eosinophilia syndrome (NARES) is a clinical syndrome comprising symptoms consistent with allergic rhinitis in which an absence of atopy has been demonstrated by allergen skin testing, and nasal cytology analysis demonstrates more than 20% eosinophils. Anosmia is a prominent feature not shared with allergic rhinitis. The pathophysiology of NARES is poorly understood, but a key component involves a self-perpetuating, chronic eosinophilic nasal inflammation with development of nasal micropolyposis and polyposis. Mast cells likely play an important role as well. NARES is a risk factor for the development of nasal polyposis and aspirin sensitivity, as well as obstructive sleep apnea. Treatment consists mainly of intranasal corticosteroids with or without the addition of second-generation antihistamines and/or leukotriene-receptor antagonists.

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References and Recommended Reading

  1. 1.

    World Health Organisation Initiative, Bousquet J, van Cauwenberge P: Allergic Rhinitis and Its Impact on Asthma (ARIA). Geneva: WHO; 2000.

  2. 2.

    Jacobs RL, Freedman PM, Boswell RN: Nonallergic rhinitis with eosinophilia (NARES syndrome). Clinical and immunologic presentation. J Allergy Clin Immunol 1981, 67:253–262.

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Settipane RA, Lieberman P: Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 2001, 86:494–507.A recent and thorough review on the topic of nonallergic rhinitis

    PubMed  CAS  Google Scholar 

  4. 4.

    van Cauwenberge P, Wang D-Y, Ingels KJAO, Bachert C: Rhinitis: the spectrum of the disease. In Asthma and Rhinitis. Edited by Busse WW, Holgate ST. Oxford: Blackwell Science; 2000:6–13.

    Google Scholar 

  5. 5.

    Schiavano D, Nucera E, Milani A, et al.: Nasal lavage cytometry in the diagnosis of nonallergic rhinitis with eosinophilia syndrome (NARES). Allergy Asthma Proc 1997, 18:363–366.

    Article  Google Scholar 

  6. 6.

    Mygind N, Dirkasen A, Johnsen NJ, Weeke B: Perennial rhinitis: an analysis of skin testing, serum IgE and blood and smear eosinophilia in 201 patients. Clin Otolarygol 1978, 3:189–196.

    CAS  Google Scholar 

  7. 7.

    Mullarkey MF, Hill JS, Webb DR: Allergic and non-allergic rhinitis: their characterization with attention to the meaning of nasal eosinophilia. J Allergy Clin Immunol 1980, 65:122–126.

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Settipane GA, Klein DE: Non allergic rhinitis: demography of eosinophils in nasal smear, blood total eosinophil counts and IgE levels. N Engl Reg Allergy Proc 1985, 6:363–366.

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Crobach M, Hermans J, Kaptein A, et al.: Nasal smear eosinophilia for the diagnosis of allergic rhinitis and eosinophilic non-allergic rhinitis. Scand J Prim Health Care 1996, 14:116–121.

    PubMed  CAS  Google Scholar 

  10. 10.

    Moneret-Vautrin DA, Hsieh V, Wayoff M, et al.: Nonallergic rhinitis with eosinophilia syndrome a precursor of the triad: nasal polyposis, intrinsic asthma, and intolerance to aspirin. Ann Allergy 1990, 64:513–518.

    PubMed  CAS  Google Scholar 

  11. 11.

    Kramer MF, de la Chaux R, Fintelmann R, Rasp G: NARES: A risk factor for obstructive sleep apnea? Am J Otolaryngol 2004, 25:173–177.

    PubMed  Article  Google Scholar 

  12. 12.

    Fokkens WJ: Thoughts on the pathophysiology of nonallergic rhinitis. Curr Allergy Asthma Rep 2002, 2:203–209.

    PubMed  Article  Google Scholar 

  13. 13.

    Leone C, Teodoro C, Pelucchi A, et al.: Bronchial responsiveness and airway inflammation in patients with nonallergic rhinitis with eosinophilia syndrome. J Allergy Clin Immunol 1997, 100:775–780.

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Marshall KG, Attia EL, Danoff D: Vasomotor rhinitis. In Disorders of the Nose, Paranasal Sinuses. Edited by Marshall KG, Attia EL. Littleton: PSG Publishing; 1987:195–203.

    Google Scholar 

  15. 15.

    Moneret-Vautrin DA, Jankowski R, Wayoff M: [Clinical and pathogenic aspects of NARES (non-allergic rhinitis with eosinophilic syndrome)]. Rev Laryngol Otol Rhinol (Bord ) 1991, 112:41–44.

    CAS  Google Scholar 

  16. 16.

    Di Lorenzo G, Drago A, Pellitteri ME, et al.: Measurement of inflammatory mediators of mast cells and eosinophils in native nasal lavage fluid in nasal polyposis. Int Arch Allergy Immunol 2001, 125:164–175.

    Article  Google Scholar 

  17. 17.

    Craig SS, Schwartz LB: Tryptase and chymase, markers of distinct types of human mast cells. Immunol Res 1989, 8:130–138.

    PubMed  CAS  Article  Google Scholar 

  18. 18.

    Schwartz LB, Kawahara MS, Hugli TE, et al.: Generation of C3a anaphylatoxin from human C3 by human mast cell tryptase. J Immunol 1983, 130:1891–1895.

    PubMed  CAS  Google Scholar 

  19. 19.

    Togias A, Naclerio RM, Proud D, et al.: Studies on the allergic and nonallergic nasal inflammation. J Allergy Clin Immunol 1988, 81:782–790.

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Kramer MF, Rasp G: Nasal polyposis: eosinophils and interleukin-5. Allergy 1999, 54:669–680.

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Klimek L, Rasp G: Norm values for eosinophil cationic protein in nasal secretions: influence of specimen collection. Clin Exp Allergy 1999, 29:367–374.

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Kramer MF, Burow G, Pfrogner E, Rasp G: In vitro diagnosis of chronic nasal inflammation. Clin Exp Allergy 2004, 34:1086–1092. The most recent evaluation into differences in pathophysiology between NARES, nasal polyposis, allergic rhinitis, and sinusitis; provides useful insights into the same.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    Bousquet J, Chanez P, Lacoste JY, et al.: Eosinophilic inflammation in asthma. N Engl J Med 1990, 333:1033–1039.

    Article  Google Scholar 

  24. 24.

    Flavahan NA, Slifman NR, Gleich GJ, Vanhoutte PM: Human eosinophil major basic protein causes hyperreactivity of respiratory smooth muscle. Am Rev Respir Dis 1988, 138:685–688.

    PubMed  CAS  Google Scholar 

  25. 25.

    Venge P, Dahl R, Fredens K, Peterson CG: Epithelial injur y by human eosinophils. Am Rev Respir Dis 1988, 138:S54-S57.

    PubMed  CAS  Google Scholar 

  26. 26.

    Hastie AT, Loegering DA, Gleich GJ, Kueppers F: The effect of purified human eosinophil major basic protein on mammalian ciliary activity. Am Rev Respir Dis 1987, 135:848–853.

    PubMed  CAS  Google Scholar 

  27. 27.

    Davidson AE, Miller SD, Settipane RJ, et al.: Delayed nasal mucociliary clearance in patients with nonallergic rhinitis and nasal eosinophilia. Allergy Proc 1992, 13:81–84.

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Baraniuk J: Neuroregulation. Proceedings of the St.Thomas Aventis Meeting, 1-14. 2000.

  29. 29.

    Baraniuk J, Silver PB, Kaliner MA, Barnes PJ: Perennial rhinitis subjects have altered vascular, glandular, and neural responses to bradykinin nasal provocation. Int Arch Allergy Immunol 2005, 103:202–208.

    Article  Google Scholar 

  30. 30.

    Ricchio MM, Reynolds CJ, Hay DW, Proud D: Effects of intranasal administration of endothelin-1 to allergic and non-allergic individuals. Am J Respir Crit Care Med 1995, 152:1757–1764.

    Google Scholar 

  31. 31.

    Ricchio MM, Proud D: Evidence that enhanced neural reactivity to bradykinin in patients with symptomatic allergy is mediated by neural reflexes. J Allergy Clin Immunol 1996, 97:1252–1253.

    Article  Google Scholar 

  32. 32.

    Wilde AD, Cook JA, Jones AS: The nasal response to isometric exercise in non-eosinophilic intrinsic rhinitis. Clin Otolaryngol 1996, 21:84–86.

    PubMed  Article  CAS  Google Scholar 

  33. 33.

    Powe DG, Huskisson RS, Carney AS, et al.: Evidence for an inflammatory pathophysiology in idiopathic rhinitis. Clin Exp Allergy 2001, 31:864–872.

    PubMed  Article  CAS  Google Scholar 

  34. 34.

    Romero JN, Scadding GK: Eosinophilia in nasal secretions compared to skin prick test and nasal challenge test in the diagnosis of nasal allergy. Rhinology 1992, 30:169–175.

    PubMed  CAS  Google Scholar 

  35. 35.

    Powe DG, Jagger C, Kleinjan A, et al.: "Entopy": localized mucosal allergic disease in the absence of systemic responses for atopy. Clin Exp Allergy 2003, 33:1374–1379. Further evidence to support the hypothesis that perhaps "non-allergic" rhinitis is actually allergic but with only local manifestations (ie, local IgE production).

    PubMed  Article  CAS  Google Scholar 

  36. 36.

    Carney AS, Powe DG, Huskisson RS, Jones NS: Atypical nasal challenges in patients with idiopathic rhinitis: More evidence for the existence of allergy in the absence of atopy? Clin Exp Allergy 2002, 32:1436–1440.

    PubMed  Article  CAS  Google Scholar 

  37. 37.

    Scadding GK: Non-allergic rhinitis: diagnosis and management. Curr Opin Allergy Clin Immunol 2001, 1:15–20.

    PubMed  CAS  Google Scholar 

  38. 38.

    Keith P, Dolovich J: Allergy and nasal polyposis. In Nasal polyposis-An Inflammatory Disease and Its Treatment. Edited by Mygind N, Lildholdt T. Copenhagen: Munksgaard; 1997:68–77.

    Google Scholar 

  39. 39.

    Redegeld F, van der Heijden M, Kool M, et al.: Immunoglobulin-free light chains elicit immediate hypersensitivity- like responses. Nature Med 2002, 8:694–701.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Kraneveld A, Kool M, van Houwelingen A, et al.: Elicitation of allergic asthma by immunoglobulin free light chains. PNAS 2005, 102:1578–1583.

    PubMed  Article  CAS  Google Scholar 

  41. 41.

    Webb DR, Meltzer EO, Finn AF Jr, et al.: Intranasal fluticasone propionate is effective for perennial nonallergic rhinitis with or without eosinophilia. Ann Allergy Asthma Immunol 2002, 88:385–390.

    PubMed  CAS  Article  Google Scholar 

  42. 42.

    Mygind N: Effects of corticosteroid therapy in non-allergic rhinosinusitis. Acta Otolaryngol 1996, 116:164–166.

    PubMed  CAS  Google Scholar 

  43. 43.

    Mygind N, Lildholdt T: Nasal polyps treatment: medical management. Allergy Asthma Proc 1996, 17:275–282.

    PubMed  Article  CAS  Google Scholar 

  44. 44.

    Purello-D’Ambrosio F, Isola S, Ricciardi L, et al.: A controlled study on the effectiveness of loratadine in combination with flunisolide in the treatment of nonallergic rhinitis with eosinophilia (NARES). Clin Exp Allergy 1999, 29:1143–1147.

    PubMed  Article  CAS  Google Scholar 

  45. 45.

    Peters-Golden M, Henderson WR Jr: The role of leukotrienes in allergic rhinitis. Ann Allergy Asthma Immunol 2005, 94:609–618.

    PubMed  CAS  Google Scholar 

  46. 46.

    Berges-Gimeno MP, Simon RA, Stevenson DD: The effect of leukotriene-modifier drugs on aspirin-induced asthma and rhinitis reactions. Clin Exp Allergy 2002, 32:1491–1496.

    PubMed  Article  CAS  Google Scholar 

  47. 47.

    Bachert C, Watelet JB, Gevaert P, Van Cauwenberge P: Pharmacological management of nasal polyposis. Drugs 2005, 65:1537–1552.

    PubMed  Article  CAS  Google Scholar 

  48. 48.

    Saito H, Morikawa H, Howie K, et al.: Effects of a cysteinyl leukotriene receptor antagonist on eosinophil recruitment in experimental allergic rhinitis. Immunology 2004, 113:246–252.

    PubMed  Article  CAS  Google Scholar 

  49. 49.

    Menzies-Gow A, Flood-Page P, Sehmi R, et al.: Anti-IL-5 (mepolizumab) therapy induces bone marrow eosinophil maturational arrest and decreases eosinophil progenitors in the bronchial mucosa of atopic asthmatics. J Allergy Clin Immunol 2003, 111:714–719.

    PubMed  Article  CAS  Google Scholar 

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Correspondence to Paul K. Keith MD, MSc, FRCPC.

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Ellis, A.K., Keith, P.K. Nonallergic rhinitis with eosinophilia syndrome. Curr Allergy Asthma Rep 6, 215–220 (2006).

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  • Obstructive Sleep Apnea
  • Rhinitis
  • Allergic Rhinitis
  • Allergic Rhinitis
  • Allergy Clin Immunol