LA TRIADE DI WIDAL - siaaic-toscoemiliana.org · La triade di Widal ha cento anni e non li dimostra Dott.ssa Benedetta Biagioni. Journal of Asthma and Allergy 2019 La triade di Widal

LA TRIADE DI WIDAL

HA CENTO ANNI

…E NON LI DIMOSTRA

Dott.ssa Benedetta Biagioni

La triade di Widal ha cento anni e non li dimostra Dott.ssa Benedetta Biagioni

1897

1922 1967

The «triad» history

Felix Hoffmann • 1897, acetylated salicylic firstly produced

• 1899, «aspirin» selled around the world


Fernand Georges Isidore Widal

After an oral challenge with aspirin,a female volunteer with all thehallmarks of underlying respiratorydisease had an asthma attack,profuse rhinorrhea, and urticaria.The same reactions occurred afteroral challenges with antipyrine, theonly other available nonsteroidalantiinflammatory drug (NSAID)

Widal F, Abrami P, Lermoyez J. Anaphylaxie et idiosyncrasie. Presse Med 1922; 30: 189-93.

• 1922 first case report


Max Samter

• 1967 first «Triad» definition by Samter and Beer:

Samter M, Beers RF Jr. Concerning the nature of intolerance to aspirin. J Allergy 1967; 40: 281-93.


• 0.3-0.9% of the general population

• 5.5% to 12.4% of adult asthmatics (the mean prevalence , 7.1% ),

• 14.9% among patients with severe asthma and up to 24% in patients

admitted to the Intensive Care Unit (ICU )

• Usually diagnosed in the 3 - 4th decade of life

• F>M

• All countries except China

• 5% of children with asthma frequent extra -pulmonary symptoms

(urticaria /angioedema or diarrhea and abdominal pain) after NSAIDs

The «triad» Epidemiology:


• Despite avoidance of NSAIDs, chronic airway symptoms persist

• AERD does not preclude other provoking mechanisms: viral infections, gastroesophageal reflux, irritant provocations, exercise-induced exacerbations, IgE-mediated

• Increased prevalence of respiratory symptoms after consuming alcoholic beverages (> red wine and beer)

• Less commonly gastrointestinal and/or cutaneous manifestations

The «triad» hallmarks:


The «triad» hallmarks: NSAID induced reactions

• Reactions are triggered by first exposure to any NSAID

• Reaction to aspirin or other NSAID develop within 30 -180 minutes. The reaction usually starts with nasal congestion and/or rhinorrhea, followed by asthma symptoms

• In patients with unstable asthma the symptoms may appear much faster, progressing rapidly to severe bronchospasm

• Onset and severity of the reaction are dose -related

• The threshold dose varies between 10 - 300 mg, but 60 mg of ASA would induce symptoms in a majority of patients


Journal of Asthma and Allergy 2019


n engl j med 379;11 nejm.org September 13, 2018


• Upper respiratory symptoms are worse in N -ERD patients than in NSAIDs -tolerant CRSwNP patients

• Anosmia occur more frequently in N-ERD patients and may be considered a clinical marker to identify N -ERD patients

• Recurrence of nasal polyps after surgery is more frequent

• Rhinoscopy or nasal endoscopy findings

• Upper CT scan more severe sinus opacification and extension

The «triad» hallmarks: CRSwNP


The «triad» hallmarks: CRSwNP


• The majority of N -ERD patients suffer from moderate to severe asthma.

• The prevalence of severe asthma among N -ERD patients 15%, twice the general asthma population.

• The risk of uncontrolled asthma in N -ERD patients is increased 2–fold

• Severe asthma increase by 60%

• Emergency room visits increase by 80%

• Asthma hospitalization increase by 40%

The «triad» hallmarks: asthma




AERD Pathophysiology

n engl j med 374;5 nejm.org February 4, 2016


AERD Pathophysiology

n engl j med 374;5 nejm.org February 4, 2016


Urinary LTE4 concentrationin AERD

Adapted from Kawagishi Y et al. J Allergy Clin Immunol 2002



Allergy. 2019 Jan


Allergy. 2019 Jan


Allergy. 2019 Jan


The «triad» managment:

Avoidance of NSAIDs

Alcohol avoidance

Asthma Therapy (GINA guidelines)

Leukotriene-modifying drugsMontelukast, Zileuton

Low salicylate diet ?

CRS management

Biologics

Aspirin desensitization and high dose aspirin therapy


Allergy. 2019 Jan

Aspirin desensitization


Allergy. 2019 Jan







Clin Rev Allergy Immunol. 2019 May 10


World Allergy Organization Journal 12 (2019) 100050



Dott.ssa Benedetta Biagioni

Grazie per l’attenzione!

Documents

LA TRIADE DI WIDAL - siaaic-toscoemiliana.org · La triade di Widal ha cento anni e non li dimostra Dott.ssa Benedetta Biagioni. Journal of Asthma and Allergy 2019 La triade di Widal