Alergiile sezoniere

2 Septembrie, 2010 - 23:00

Dr. Jeana Rodica Radu
Profesor universitar - UMF "C.Davila" Catedra Alergologie - Spitalul Clinic "N.Malaxa"

Termenul de alergii sezoniere defineste un manunchi de boli alergice IgE mediate particularizate, in general, prin evolutie intermitenta, dependenta de variatiile sezoniere ale concentratiilor alergenelor ce actioneaza ca inductori ai sensibilizarii si/sau ca factori declansatori ai simptomelor clinice ce le caracterizeaza jogos casino online.

Delimitari Din punct de vedere epidemiologic, alergiile sezoniere care includ rino-conjunctivitele si astmul sezonier, reprezinta cele mai raspandite, cunoscute si investigate boli atopice.

Mult mai rar, intre alergiile sezoniere pot fi incadrate si anafilaxiile sau reactiile sistemice de diferite grade de severitate (vezi clasificarea Muller) cauzate de expunerea brutala/intempestiva la polenuri, precum si urticariile de contact cu aceste alergene, declansate in sezonul specific Bonus Fara Depunere

Etio-patogenic, alergiile sezoniere cu expresie rino-conjuctivala si bronsica sunt corelate cu expunerea la alergene a caror variatie cantitativa este dependenta de factori climatici, intre cele incriminate fiind enumerate: polenurile, dar si mucegaiurile si chiar acarienii, care pot
avea o dezvoltare accentuata sezoniera.

In clinica, si de aici uzual, termenul de alergii sezoniere se atribuie limitativ bolilor conjunctivei si cailor aeriene superioare si inferioare, provocate de expunerea si reexpunerea la polenuri. Cunoscute ca rino-conjunctivite si astm sezonier, acestea sunt denumite sub termenul generic polinoze.

Polenurile - principalele alergene in bolile sezoniere

Polenurile se prezinta sub forma de granule cu morfologie, dimensiuni si alte caracteristici specifice de specie.

Functional, granulele de polen reprezinta celulele sexuate masculine, cu rol in reproducerea plantelor cu seminte, fiind purtatoarele gametilor masculini dispersati pe gametii feminini ai altei plante din aceeasi specie.

Modalitatea de vehiculare a polenurilor diferentiaza plantele anemofile (polenizate de vant) de cele entomofile (polenizate mediat de insecte, omizi, mici animale cu blana, serpi etc.).

Principala sursa de polenuri alergizante este asigurata de plantele anemofile, ale caror granule de polen au variatii dimensionale intre 2 si 60 mm in diametru. Acestea sunt aeropurtate si dispersate pe arii extinse. Plantele entomofile nu reprezinta decat un rezervor alergenic limitat (neimportant cantitativ si cu o arie de dispersie limitata).

Polenizarea este asociata perioadei de inflorire a plantelor, caracteristica diferitelor specii. Pentru zona noastra geografica, la sfarsitul iernii (februarie) si in perioada primaverii timpurii (martie, aprilie) infloresc arborii din familia Betulaceae Betula verrucosa (mesteacan), Corylus
avellana (alun), Alnus glutinosa (arin) si unele Salicaceae - Salix caprea (un tip de salcie) si Populus deltoides (plopul).

Pentru acestea, perioada de polenizare variaza intre cateva zile pana la doua saptamani, polenurile de dimensiuni mari fiind cross reactive si emise abundent; ele induc fenomene de rino-conjunctivita.

Mai putin importante pentru sensibilizare sunt polenurile de Quercus robur (stejar), Ulmus camperi (ulm) si Platanus acelifolia (platan) iar polenul de Fagus silvatica (fag) nu produce deloc sensibilizari. Numarul indivizilor sensibilizati la polenuri de arbori timpurii nu este nici el important.

Coniferele sunt arbori care isi pastreaza frunzele pe toata durata anului; unele specii de conifere induc polenuri corelate cu alergia sezoniera. Asa sunt: Cryptomeria japonica (cedrul japonez) responsabil de polinoze manifestate in perioada februarie-aprilie, ca si Juniperus ashei (cedrul de munte) si Cupressus sempervireus (chiparosul).

Polenul de Pinus silvestris (pin), desi extrem de abundent, are si el o alergenicitate redusa.

Primavara tarzie (mai) pana la mijlocul verii (iulie) este perioada de polenizare a gramineelor de cultura si salbatice, larg raspandite la noi si puternic sensibilizante, cross reactive. Dintre acestea fac parte Povideae-le: Lolium perenne (zizania, iarba de gazon), Dactylis glomerata
(golomat, golomoz), Festuca rubra (paius rosu), Holcus lanatus, Phleum pratense (timoftica) etc.

Ierburile buruieni sunt plante salbatice, cu polenizare peranuala, dar cu varfuri sezoniere concomitente cu gramineele, iar pentru unele (ambrosia), polenizarea se face in lunile august-septembrie.

Cele mai importante ierburi alergogene sunt reprezentate de: Artemisia vulgaris si Parientaria judaica, Ambrosia artemisifolia si Ambrosia trifida, Urtica dioica (urzica mare), Rumex acetosella (macrisul marunt), Plantago lanceolata (patlagina ingusta).

Si intre polenurile de ierburi exista reactii incrucisate, care se pot extinde si la alergenele din Compositae.

Exista numeroase stari alergice, fie cu expresie multiorganica (anafilaxie), fie cu expresie in principal digestiva (sindromul oral) induse de cross reactivitatea intre polenuri si unele alimente.

Remarcabile sunt reactiile incrucisate intre:

a) arbori timpurii (betula verrucosa - mesteacan) si alte belulaceae (Corylus avellana, Alnus glutinosa) si fructe, in special - Rosaceae (mar, par, cais, piersic, capsuni, prun, kiwi), dar si nuci, migdale, alune, legume /vegetale (cartof, morcov, tomate);

b) graminee (cross reactivitate intre specii) si leguminoase (soia, mazare), arahide, graminacee cerealiere si faina de cereale;

c) ierburi/buruieni ca artemisia vulgaris si compositae (floarea soarelui, musetel), vermut, vegetale condimente (umbeliferae si alte familii): selina, pastarnac, morcov, piper alb, boia, patrunjel, arpagic, pepene galben, banana sau intre Ambrosia si Curcubitaceae (pepene verde, galben, cantalup, castravete) si banana.

Numerosi alergeni proveniti din polenuri au fost identificati, caracterizati, iar o parte si clonati.

Au fost identificati epitopii principali din grupurile I-V din Lolium perrene, Sorglum balepense, Poa pratensis ca si din numeroase alte polenuri, fiind izolat si citocromul C (grupul X).

Clonarea aminoacizilor din unele polenuri a fost utila pentru caracterizarea fenomenului de legare a epitopilor la IgE si celula T ca si la initierea imunoterapiei cu alergene recombinate.

Tabloul clinic caracteristic alergiilor sezoniere

Debutul simptomelor ce caracterizeaza alergiile sezoniere este cel mai adesea, lent progresiv. Tabloul clinic multiorganic, variaza de la discret pana la intens zgomotos, afectand frecvent conjunctiva si caile aeriene superioare.

Subiectii cu polinoza acuza: prurit oculo-nazal, faringian si chiar otic, lacrimare, injectie conjunctivala, senzatie de corp strain intraocular, uneori fotofobie, edem palpebral; la aceste semne se adauga stranuturi in salve, hidroree, blocaj nazal intermitent, tuse in accese, disfonie, wheesing izolat si dispnee in accese de tip astmatic.

Fenomenele clinice sunt corelate cu expunerea la polenuri fiind declansate cel mai adesea in aer liber.

Gravitatea tabloului clinic variaza de la o zi la alta in functie de conditiile de expunere, fiind dependenta in principal de concentratia polenurilor in mediu.

Sunt descrise cateva conditii care pot majora severitatea evolutiei, intre care importante sunt: sensibilizarea si inflamatia alergica preexistenta indusa de alergene peranuale, hiperreactivitatea bronsica nespecifica crescuta, care complica severitatea crizelor de astm sezonier, conjunctivita sicca (majoreaza rata sensibilizarii prin lipsa lacrimilor ce ar trebui sa
impiedice contactul cu granulele de polen).

Diagnosticul alergiilor sezoniere

Diagnosticul alergiilor sezoniere este bazat pe un trepied ce consta din:
- anamneza
- determinarea tipurilor si concentratiei de polenuri in mediu
- teste de identificare a alergenelor sezoniere (dozare IgE specifice in vitro sau teste de provocare in vivo - testare cutanata, de regula prin intepatura, teste prick) sau conjunctivale - aplicarea extractelor standardizate in sacul conjunctival intern si determinarea cantitatii de lacrimi si a proteinelor/mediatorilor continuti in acestea, in
paralel cu monitorizarea conjunctivitei/rinitei induse, provocari nazale si bronsice pe cale naturala prin expunere (in camp/parc) si monitorizarea simptomelor induse, urmarirea raspunsului la tratament.

Tratamentul bolilor alergice sezoniere

Tratamentul bolilor alergice sezoniere este complex, durata aplicarii lui ca si diversitatea schemei terapeutice fiind dependente de:
- durata expunerii la polenuri si de agresivitatea acestora
- interesarea mono/pluriorganica
- gradul de severitate evolutiva
- posibile asocieri morbide, ce necesita tratamente incompatibile cu unele procedee terapeutice (ca incompatibilitatea intre imunoterapia cu vaccinuri alergenice si tratamentul cu beta-blocante si inhibitorii enzimei de conversie a angiotensinei)
- complianta la terapie a individului afectat.

Planul terapeutic al alergiilor sezoniere impune:
- asigurarea mijloacelor de evitare partiala/totala a alergenelor
- modularea raspunsurilor celulelor implicate in inflamatia alergica indusa de polenuri prin folosirea stabilizatorilor de membrana celulara
- farmacoterapia antimediatori (antihistaminice, antileucotriene)
- farmacoterapie antiinflamatorie (nesteroidiana si - in cazuri exceptional severe - steroidiana)
- imunoterapia cu vaccinuri alergenice/vaccinuri recombinante, aplicata pre-sezonier sau peranual.

Profilaxia contactului cu polenurile este dintre cele mai dificile interventii limitative de contact. Ea include:
- evitarea in sezon a activitatilor in aer liber, cel putin in orele de densificare polenica;
- circulatia cu geamurile masinii inchise si cu folosirea aerului conditionat cu filtre inalt performante;
- folosirea ochelarilor/mastilor de protectie, atunci cand expunerea in aer liber este obligatorie;
- spalarea conjunctivei bulbare si mucoasei nazale pentru eliminarea granulelor depolen.

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