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What causes persistent stuffy nasal cavities and allergy?

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Posted on Tue, 7 Jun 2016
Question: THIS IS A REQUEST FOR SECOND OPINION

The essentials of my dilemma are these:

Long-time allergy/hay fever sufferer. Typically, I respond poorly to non-sedating antihistamines. On occasion, I require antibiotics and oral/injectable steroids.

I am HIV+, with neg. viral loads and CD4s in the 600s. I have RAD on beta-agonists and inhaled steroids.

Most recently, I was placed on levaquin which did not reduce my sinus tenderness. Since I can only use decongestants twice daily, I walk around with persistent nasal stuffiness, and occasional epistaxis. For the last month, the allergist has treated me with amoxicillin and prednisone, slowly tapering the steroid over a month.

Allergy testing + only for dog/cat. I am on desensitization shots qmonth for this (I own a service-dog). All immunoglobulins are barely normal. Sinus CT: mildly deviated septum and findings c/w mucosal thickening in all sinuses.

Do I need to be concerned about a primary immunodeficiency in addition to the immunodeficiency of HIV? How low do the immunoglobulins have to be before one considers whether or not a primary immunodeficiency exists?

Finally, what is Churg-Strauss syndrome? Does it present with symptoms such as what I've described?

doctor
Answered by Dr. Kaushal Bhavsar (2 hours later)
Brief Answer:
Possibility of churg Strauss disease is less likely in your case.

Detailed Answer:
Thanks for your question on Healthcare Magic.
I can understand your concern.
For the diagnosis of primary immunodeficiency syndrome, you need to get done serum levels of IgG, IgA and IgM.
If their levels are less than 50% of normal then you might have primary immunodeficiency syndrome.
But with the background of HIV illness, it is very difficult to diagnose primary immunodeficiency syndrome.
Possibility of churg Strauss disease is also less likely.
Because it is almost always have asthma like symptoms (97% patients) followed by allergic rhinitis, paranasal sinusitis, lung Infiltrate (transient) and skin lesions.
So please let me know
1. Do you have asthma like symptoms!
2. What is you chest x ray report?
Please reply me answers of above asked questions, so that I can guide you better. I will be happy to help you further. Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (50 minutes later)
I DO have asthma that was demonstrated by PFTs. My most recent CXR (taken before my latest asthma/allergy exacerbation) showed low lung volumes but no infiltrates. Prior to that, a chest CT showed bilateral emphysema, bilateral lower lube and left upper lobe scarring. (PFTs were not c/w emphysema -- how does the radiologist make this dx? by flattened diaphragms?) I also have a stable right lung solitary pulmonary nodule. More than a year ago, CXR showed an effusion on the right that was present for about 2 months after an inpatient admission for CAP.
doctor
Answered by Dr. Kaushal Bhavsar (35 minutes later)
Brief Answer:
Do you smoke?

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
Following are the CT criterias for diagnosis of emphysema.
1. Increased intercostal spaces
2. Tear shaped heart
3. Flattened diaphragm
4. Air trapping etc.
So you had lung nodule and effusion and CAP in the past.
Please let me know
1. Do you smoke?
2. Which drugs are you taking for HIV?
Please reply me answers of above asked questions, so that I can guide you better. I will be happy to help you further. Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (27 minutes later)
I am a lifetime non-smoker.

HIV meds: abacavir, raltegravir, lamivudine
doctor
Answered by Dr. Kaushal Bhavsar (1 hour later)
Brief Answer:
Have you ever undergone IgE level?

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
I want to know few more things about your illness.
1. Have you ever undergone bronchoscopy and XXXXXXX (bronchoalveolar lavage) analysis?
2. Have you ever undergone anti tubercular drugs or anti fungal drugs?
3. Have you ever tested for IgE level?
4. Have you ever tried montelukast (anti allergic)?
Please reply me answers of above asked questions, so that I can guide you better. I will be happy to help you further. Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (2 hours later)
My eosinophils are perennially high, both absolute and %, but not high enough for the diagnosis of hypereosinophilia.

A recent surveillance EGD done for HCC screening revealed elevated tissue eosinophils, but once again not enough for eosinophilic esophagitis.

1) I have never undergone bronchoscopy w/BAL or surgical treatment for SPN.
2) I have never been placed on anti-TB drugs nor oral/IV antifungal drugs.
3) IgA: 0.04 g/dL (nl .09-.45); IgG: 0.80 g/dL (0.8-1.8); IgM: 0.06 g/dL (.06-.25); IgE: 26 IU/mL (0-158) [reference ranges are for lab my doctor uses] Serum Allergens: Cat hair (Class III); Mountain Cedar (Class I); Dog epithelia (Class IV); All others were Class 0.
4) I have never been prescribed/taken montelukast.
I have been told that if serum IgA is low, that IgA in tissue and its secretions is also low. Is this correct?

Does my low serum IgA mean I have partial IgA deficiency? (I've been told that selective IgA deficiency would have nearly undetectable levels of IgA.)

If I am HIV+ with low IgA, does that mean that a lower threshold should be used for the use of antibiotics with respiratory symptoms?
doctor
Answered by Dr. Kaushal Bhavsar (22 minutes later)
Brief Answer:
No, this is not true.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
I can understand your concern.
No, this is not true.
Low IgA level does not mean that you need lower dose of antibiotic. Who told you so?
And what about montelukast?
Have you ever tried this?
Please reply me answers of above asked questions, so that I can guide you better. I will be happy to help you further. Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Kaushal Bhavsar (4 minutes later)
There must have been a misunderstanding:

I meant to say (perhaps clumsily) that I was told that having a selective or partial IgA deficiency (even in patients without HIV) should cause the clinician to be MORE LIKELY to prescribe antibiotics when there is a possibility that an upper respiratory infection exists. Is this true?

I have never used montelukast.
doctor
Answered by Dr. Kaushal Bhavsar (51 minutes later)
Brief Answer:
I don't know about others' practice but I am not giving antibiotics.

Detailed Answer:
Thanks for your follow up question on Healthcare Magic.
Sorry for misunderstanding.
I don't know about others' but I don't give antibiotics even if there is partial deficiency of IgA.
In my opinion, you should definitely start montelukast. It is anti allergic drug and will mostly help you.
I don't think you are having churg Strauss disease or primary immunoglobulin deficiency.
For your sinus problem, best thing is endoscopic evaluation of sinuses and if needed Biopsy.
Hope I have solved your query.
If you are having further queries, then please close the conversation and rate my answer.
You can ask me directly on bit.ly/askdrkaushalbhavsar.
Wish you good health. Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Dr. Kaushal Bhavsar

Pulmonologist

Practicing since :2008

Answered : 14687 Questions

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What causes persistent stuffy nasal cavities and allergy?

Brief Answer: Possibility of churg Strauss disease is less likely in your case. Detailed Answer: Thanks for your question on Healthcare Magic. I can understand your concern. For the diagnosis of primary immunodeficiency syndrome, you need to get done serum levels of IgG, IgA and IgM. If their levels are less than 50% of normal then you might have primary immunodeficiency syndrome. But with the background of HIV illness, it is very difficult to diagnose primary immunodeficiency syndrome. Possibility of churg Strauss disease is also less likely. Because it is almost always have asthma like symptoms (97% patients) followed by allergic rhinitis, paranasal sinusitis, lung Infiltrate (transient) and skin lesions. So please let me know 1. Do you have asthma like symptoms! 2. What is you chest x ray report? Please reply me answers of above asked questions, so that I can guide you better. I will be happy to help you further. Wish you good health. Thanks.