Next Steps for a Patient with Elevated IgE Levels but No Allergic Rhinitis Symptoms and Negative Allergy Test
For a patient with elevated IgE levels but no allergic rhinitis symptoms and negative allergy test results, the most appropriate next step is to evaluate for non-allergic causes of elevated IgE and consider referral to an allergist/immunologist for further specialized assessment.
Diagnostic Considerations
Positive skin tests or in vitro tests for specific IgE must be correlated with history and physical findings to assess their clinical significance - a positive test without symptoms is not diagnostic of allergic rhinitis 1
Patients who have negative immediate hypersensitivity skin test reactions or negative in vitro tests for specific IgE should be considered nonallergic, especially if there is poor correlation between allergen exposure and symptoms 1
A complete blood count with differential should be performed to assess for eosinophilia in patients with elevated IgE levels 2
Consider nasal smear examination for eosinophils, as some patients with negative skin tests but nasal eosinophilia may have nonallergic rhinitis with eosinophilia syndrome (NARES) 1
Potential Diagnoses to Consider
Nonallergic rhinitis syndromes, which are characterized by periodic or perennial symptoms of rhinitis that are not a result of IgE-dependent events 1
Local allergic rhinitis (LAR), where patients may have local IgE production in the nasal mucosa despite negative systemic allergy testing 3, 4, 5
Vasomotor rhinitis (idiopathic rhinitis), which accounts for a heterogeneous group of patients with chronic nasal symptoms that are not immunologic or infectious in origin 1
NARES, characterized by nasal eosinophils in patients who have perennial symptoms and occasionally reduced sense of smell 1
Recommended Evaluation
Consider fiber optic nasal endoscopy, which may be especially useful when symptoms or physical findings are atypical, complications or other conditions are suspected, or symptoms do not respond adequately to therapy 1
In select cases, nasal allergen provocation testing may be considered to identify local allergic reactions despite negative skin tests and serum specific IgE 4, 5
Evaluate for possible local IgE production in the nasal mucosa, as the airway mucosa has the intrinsic capability to produce IgE independently of IgE serum levels and atopic status 3, 6
Consider CT or MRI imaging if complications or comorbidities such as nasal polyposis and/or concomitant sinusitis are suspected 1
Treatment Approach
For patients with nonallergic rhinitis, intranasal corticosteroids are recommended as first-line treatment, effectively relieving both congestion and rhinorrhea associated with vasomotor rhinitis 7
Intranasal antihistamines, such as azelastine, are effective for nonallergic rhinitis, particularly for vasomotor rhinitis 7, 8
Intranasal anticholinergics, such as ipratropium bromide, are particularly effective for treating rhinorrhea in nonallergic rhinitis 7, 9
Avoid nonsedating oral antihistamines in nonallergic rhinitis as they have not been shown to be effective 7
When to Refer
Referral to an allergist/immunologist is recommended for prolonged manifestations of rhinitis not responding to standard therapy 7, 9
Referral is also appropriate when complications such as nasal polyps develop or when IgE results are difficult to interpret in the clinical context 7, 2
Consider referral if there is suspicion of local allergic rhinitis that requires specialized testing such as nasal allergen provocation tests 4, 5
Common Pitfalls to Avoid
Overreliance on IgE testing without clinical correlation - a positive allergy test result in the absence of clinical symptoms is not adequate to make a diagnosis of allergy 2
Unnecessary dietary restrictions based solely on elevated IgE without documented food allergy 2
Prolonged use of intranasal decongestants (more than 3 days) which can lead to rhinitis medicamentosa 7
Using oral antihistamines as first-line treatment for nonallergic rhinitis, as they are generally ineffective in this condition 7, 8