Pollen allergy has already been an increasingly prominent ecosystem disservice in tourism attractions. However, few studies have assessed the tourist risk of pollen allergy through integrating multidisciplinary knowledge of ecology, medicine, phenology, and risk management. Basing on the conceptual framework of risk assessment proposed by UNISDR, we first established an index system of pollen-allergy risk for tourists in attractions and outlined assessment methods 18 available indexes were put forward to cover three aspects: hazard of plant allergen, tourist vulnerability, and resilience of assessment units. Subsequently, taking the Summer Palace as the case study area, we conducted a tourist risk assessment of pollen allergy. Values of nine available indexes were obtained via ecological investigation, phenological observation, and data mining of visitors\' logs on Sina Weibo. Risk levels of spring pollen allergy for tourists in different assessment units were revealed by combining the green zone allergenicity index model and three-dimensional risk assessment matrix. The results showed that: (1) There were seven primary pollen-allergenic plants in the Summer Palace, including Platycladus orientalis, Sabina chinensis, Salix babylonica, Pinus tabulaeformis, Populus tomentosa Carr, Morus alba L. and Fraxinus chinesis, among which Platycladus orientalis and Salix babylonica were the highest allergenic. (2) Among 18 spots, tourists faced the highest risk level of pollen allergy in spring at three spots, namely the Hall of Serenity, Hall of Benevolence and Longevity, and Gallery of Literary and Prosperity. (3) The two routes of the Long Corridor and Longevity Hill scored high on the risk level. (4) Among four areas, risk levels of the Front-hill and Rear-hill areas were high. Given the increasing spatial-temporal uncertainty of pollen allergy and tourist behaviors under global warming and urbanization, the related monitoring should be strengthened in the future. Furthermore, the dynamic and improved assessment of pollen-allergy risk should be institutionalized and be integrated into the evaluation of tourism experience quality. Tourism administration should make full use of relevant assessment results and conduct more effective risk communication.

BACKGROUND: Allergic rhinoconjunctivitis and asthma are the most common IgE-mediated diseases worldwide. Allergen-specific immunotherapy (AIT) is currently the only modifying treatment for these IgE-mediated diseases in both children and adults. Subcutaneous immunotherapy is widely used, but in patients over 65 years old, there may be an increased risk of adverse reactions and a worse response to treatment. Oral immunotherapy (OIT) has been proven to be effective and safe, but currently, in most countries, it has been licensed only for patients up to 65 years old based on its technical datasheet. So far, no studies on the efficacy and safety of this type of immunotherapy in patients older than 65 years old have been published.
METHODS: We present four patients older than 65 years old with a diagnosis of moderate seasonal rhinoconjunctivitis and moderate-persistent seasonal pollen-induced asthma. Off-label use of oral immunotherapy (OIT) for grass pollen was prescribed due to the severity of their rhinoconjunctivitis symptoms and the worsening of asthma symptoms during the spring. Improvement in the rhinoconjunctivitis and asthma symptoms was reported by all patients since the first spring season and was maintained during the following two years of follow-up. There were no systemic reactions, and only two patients initially had self-limiting oral pruritus.
CONCLUSIONS: Oral immunotherapy for pollens appears to be a convenient, effective, and safe option in older patients (>65 years) with comorbidities after a three-year treatment. This is, to the best of our knowledge, the first report on the off-label use of OIT in patients over 65 years old with symptoms of allergic rhinoconjunctivitis and asthma.

The identification of allergens is essential in the management of allergic rhinitis. Sugarcane produces anemophilic pollen. The purpose of our study is to assess the role of sugarcane pollen in the occurrence of allergic rhinitis. We conducted a case-control analytical study of patients living in a Malagasy rural commune in which sugarcane cultivation and processing are important sources of employment, from July 2017 to June 2018. We enrolled 182 patients (91 cases and 91 controls). Factors associated with the occurrence of symptoms of allergic rhinitis were: a distance of less than 500 meters between homes and sugarcane fields (OR = 1.50), being a sugarcane worker (OR=1.16) and having a family history of allergic rhinitis (OR=13.67). In addition, exposure to wind gusts (OR=0.84) and outdoor occupation (OR=0.92) were protective factors. Exposure of patients to sugarcane pollen is associated with clinical manifestations of allergic rhinitis and confirms the role of this allergen in the occurrence of the disease. Avoidance and hygiene measures are the basis of treatment.

Allergen-specific immunotherapy (AIT) is a safe, effective treatment for respiratory allergies (such as moderate-to-severe allergic rhinoconjunctivitis) that are not controlled by symptomatic medications. The indications and contraindications for AIT have been defined in international guidelines and consensus statements. However, some of these contraindications are not evidenced- based but have been deduced from the theoretical risk of an interaction between AIT disease-modifying effect and immune or inflammatory comorbidities. In the absence of clinical trial evidence, the accumulation of experience as case reports can narrow the spectrum of absolute contraindications. The majority of international guidelines list HIV infection as a contraindication to AIT. Here, we describe two cases of safe, effective sublingual birch pollen AIT in HIV-positive patients undergoing concomitant antiretroviral therapy. A 32-year-old female and a 63-year-old male sensitized to tree pollen and with clinically confirmed birch pollen allergy underwent pre- and co-seasonal sublingual birch pollen AIT for three and two pollen seasons, respectively. The therapy was associated with a marked reduction in the frequency and intensity of allergic symptoms, and the reduced use of (symptomatic) rescue medication. Mild, local, treatment-emergent adverse events were noted throughout the course of treatment but resolved spontaneously. No serious adverse events were reported. In particular, there were no obvious harmful effects on the patients\' immune status or viral load. Hence, sublingual birch pollen AIT proved to be effective and safe in two HIV-positive patients.

The aim of this study was to compare airborne levels of Phl p 1 and Phl p 5, with Poaceae pollen concentrations inside and outside of the pollen season, and to evaluate their association with symptoms in grass allergic patients and the influence of climate and pollution. The Hirst and the Burkard Cyclone samplers were used for pollen and allergen quantification, respectively. The sampling period ran from 23 March 2009 to 27 July 2010. Twenty-three patients with seasonal allergic asthma and rhinitis used an electronic symptom card. The aerosol was extracted and quantified for Phl p 1 and Phl p 5 content. Descriptive statistics, non-parametric paired contrast of Wilcoxon, Spearman\'s correlations, and a categorical principal component analysis (CatPCA) were carried out. Significant variations in pollen, aeroallergen levels, pollen allergen potency, and symptoms score were observed in this study. Phl p 5 pollen allergen potency was higher at the beginning of the 2010 grass pollen season. Presence of Phl p 1 outside the pollen season with positive O3 correlation was clinically relevant. 45.5% of the variance was explained by two dimensions in the CatPCA analysis, showing the symptom relationships dissociated in two dimensions. In the first one, the more important relationship was with grass pollen grains concentration and Phl p 5 and to a lesser extent with Phl p 1 and levels of NO2 and O3, and in the second dimension, symptoms were associated with humidity and SO2. Clinically relevant out-season Phl p 1 was found with a positive O3 correlation. The effect of climate and pollution may have contributed to the higher seasonal allergic rhinitis symptom score recorded in 2009.

BACKGROUND: The prevalence of pollen allergy has increased due to urbanization, climate change and air pollution. The effects of green space and air pollution on respiratory health of pollen allergy patients are complex and best studied in spatio-temporal detail.
METHODS: We tracked 144 adults sensitized to Betulaceae pollen during the tree pollen season (January-May) of 2017 and 2018 and assessed their spatio-temporal exposure to green space, allergenic trees, air pollutants and birch pollen. Participants reported daily symptom severity scores. We extracted 404 case days with high symptom severity scores and matched these to 404 control days. The data were analyzed using conditional logistic regression with a 1:1 case-crossover design.
RESULTS: Case days were associated with exposure to birch pollen concentration (100 grains/m3) [adjusted odds ratio 1.045 and 95% confidence interval (1.014-1.078)], O3 concentration (10 μg/m3) [1.504 (1.281-1.766)] and PM10 concentration (10 μg/m3) [1.255 (1.007-1.565)] on the day of the severe allergy event and with the cumulative exposure of one and two days before. Exposure to grass cover (10% area fraction) [0.655 (0.446-0.960)], forest cover (10% area fraction) [0.543 (0.303-0.973)] and density of Alnus (10%) [0.622 (0.411-0.942)] were protective for severe allergy, but only on the day of the severe allergy event. Increased densities of Betula trees (10%) were a risk factor [unadjusted OR: 2.014 (1.162-3.490)].
CONCLUSIONS: Exposure to green space may mitigate tree pollen allergy symptom severity but only when the density of allergenic trees is low. Air pollutants contribute to more severe allergy symptoms. Spatio-temporal tracking allows for a more realistic exposure assessment.

Sometimes allergic reactions caused by various food allergens often hidden in the composition of medications can mistakenly be diagnosed as drug allergies. Such reactions can especially be unexpected if antihistamines-virtually designed to treat allergy symptoms, are imitated. We present the case of a 37-year-old female patient with cutaneous allergic reaction initially diagnosed as drug allergy to desloratadine/aerius, a desloratadine-containing antihistamine medication. The diagnostic search began with the anamnestic data of the patient about an allergy to cooked corn in her childhood, current seasonal allergic rhinitis, and hand dermatitis probably related to her professional activity. Skin tests and additional laboratory examinations led to diagnosing corn/maize allergy manifested as both food (mainly) and pollen allergy. Besides, it was concluded that hand dermatitis also can becaused by cornstarch contained in medical gloves. Finally, based on the results of a drug challenge test performed with two desloratadine-containing medications-desloratadine/aerius containing cornstarch as an excipient and desloratadine/lordestinenot containing cornstarch, the causative significance of corn was confirmed. Thus, the initial diagnosis of drug allergy was changed to that of food allergy.

This report describes a case of persistent rhinorrhea caused by donepezil and successfully treated with azelastine in an 84-year-old male treated with donepezil for Alzheimer\'s disease (AD) who experienced excessive rhinorrhea. After initiation of donepezil for AD the patient showed increased discomfort with rhinorrhea. A trial with an oral second-generation antihistamine provided no benefit. Azelastine 0.1% nasal spray was initiated and successfully reduced the rhinorrhea. A less-oftenreported side effect of donepezil that may impact patients is rhinorrhea, also described as rhinitis or nasopharyngitis.
Cholinergic mechanisms of rhinorrhea have been previously described in the condition of vasomotor rhinitis and are not allergy-mediated though symptomatology overlaps. Azelastine is a histamine H1 antagonist indicated for vasomotor rhinitis. To our knowledge there are no previous descriptions in the literature that recommend azelastine to manage symptoms of rhinorrhea caused by treatments for AD. The adverse side effect of rhinorrhea, resulting from treatment with donepezil, can be disregarded as allergy symptoms. Instead, a trial of azelastine 0.1% nasal spray, one spray each nostril daily then titrated up to two sprays in each nostril twice daily as tolerated, may be warranted. Patients and caregivers should be aware of epistaxis as a potential side effect of azelastine, especially for patients on antithrombotic therapy.

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BACKGROUND: Extranodal NK/T-cell lymphoma, nasal type (ENKTCL-NT), is a rare aggressive subtype of non-Hodgkin lymphoma characterized by angioinvasion, angiodestruction, necrosis and strong association with Epstein-Barr virus (EBV). ENKTCL-NT occurs worldwide and is more prevalent in Asian and the Native American populations of Mexico, Central and South America. It represents approximately 10% of all peripheral T-cell lymphomas worldwide. The aim of this report is to present a rare case of ENKTCL-NT with an unusually indolent clinical course and low-grade histopathologic features.
METHODS: A 71-year-old Asian woman with a long-standing history of seasonal rhinosinusitis presented with persistent nasal congestion, cough, and fever unresponsive to antihistamines and antibiotics. Histopathological evaluation of a polypoid nasal mass revealed an atypical infiltrate with predominantly small lymphoid cells that were CD2+, surface CD3-, cytoplasmic CD3+, CD5(dim)+, CD7(dim)+, cytotoxic markers (granzyme B and perforin)+, EBER+ and CD56-. The Ki-67 proliferative index was very low (< 1%). T-cell receptor gamma gene rearrangement studies were positive for a monoclonal rearrangement, and sequencing studies identified a novel KIT mutation (p. K167 M, c. 500 A > T). A diagnosis of low-grade ENKTCL-NT was rendered.
CONCLUSIONS: Our case of ENKTCL-NT is unusual due to (1) an indolent clinical course (2) low-grade histopathologic features including a low proliferative index (3) lack of CD56 expression and (4) a novel KIT mutation. This case raises awareness of the existence of a subset of cases of ENKTCL-NT that can potentially be misdiagnosed as a reactive process, particularly in patients with recurrent chronic rhinosinusitis.