Samter's triad
Encyclopedia
Samter's triad is a medical condition consisting of asthma
, aspirin sensitivity
, and nasal/ethmoidal polyposis. It occurs in middle age (twenties and thirties are the most common onset times) and may not include any allergies.
(inflammation or irritation of the nasal mucosa), which can manifest with symptoms of sneezing, runny nose, or congestion. The disorder typically progresses to asthma, then polyposis, with aspirin sensitivity coming last. The aspirin reaction can be severe, including an asthma attack, anaphylaxis
, and urticaria
in some cases. Patients typically react to other NSAIDS
such as ibuprofen
, although paracetamol
(known as acetaminophen in the United States) is generally considered safe.
Anosmia
(lack of smell) is also typical, as the inflammation reaches the olfactory receptors in the nose.
cascade, which causes undue production of leukotrienes, a series of chemicals involved in the body's inflammatory response. When prostaglandin
production is blocked by NSAIDS like aspirin, the cascade shunts entirely to leukotrienes, causing overproduction of LT-4 and producing the severe allergy-like effects.
There may be a relationship between aspirin-induced asthma and TBX21
, PTGER2, and LTC4S.
In addition to aspirin, other vaso-dilators may induce the same reaction, such as alcohol.
Treatment formerly focused on relieving the symptoms. Even desensitized people may continue to use nasal steroids, inhaled steroids, and leukotriene
antagonists.
Leukotriene antagonists and inhibitors (montelukast
, zafirlukast
, and zileuton
) are helpful in treating Samter's.
Some patients require oral steroids to alleviate asthma and congestion, and most patients will have recurring or chronic sinusitis due to the nasal inflammation. Desensitization reduces the chance of recurrence.
(precursors of arachidonic acid), and high in omega-3 oils
, may also help.
Some people find relief of symptoms by following a low-salicylate diet such as the Feingold diet
. They may need to eliminate the other salicylate-containing foods identified by Swain in 1985 as well. For those who need them, these salicylates are listed in charts in the Feingold Handbook based on level of salicylate measured in the item. Unfortunately, any such list is only a rough guideline since amounts will vary depending on fruit/vegetable variety and where grown; in fact, organic foods have been shown to contain more salicylate than conventional produce because the plant is more likely to be under attack from pests, and salicylate is produced by the plant as protection.
"AERD" ("aspirin-exacerbated respiratory disease") adds chronic rhinosinusitis to the triad. Similarly, "AIAR" ("aspirin-induced asthma and rhinitis") by definition includes rhinitis
.
A sufferer who has not yet experienced asthma or aspirin sensitivity might be diagnosed as having:
.
Initial reports on the link between asthma, aspirin and nasal polyposis were made by Widal in 1922. Further studies were done by Samter & Beers in reports published in 1968.
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
, aspirin sensitivity
Salicylate sensitivity
Salicylate sensitivity, also known as salicylate intolerance, is any adverse effect that occurs when a normal amount of salicylate is introduced into a person's body...
, and nasal/ethmoidal polyposis. It occurs in middle age (twenties and thirties are the most common onset times) and may not include any allergies.
Signs and symptoms
Most commonly, the first symptom is rhinitisRhinitis
Rhinitis , commonly known as a stuffy nose, is the medical term describing irritation and inflammation of some internal areas of the nose. The primary symptom of rhinitis is nasal dripping. It is caused by chronic or acute inflammation of the mucous membrane of the nose due to viruses, bacteria or...
(inflammation or irritation of the nasal mucosa), which can manifest with symptoms of sneezing, runny nose, or congestion. The disorder typically progresses to asthma, then polyposis, with aspirin sensitivity coming last. The aspirin reaction can be severe, including an asthma attack, anaphylaxis
Anaphylaxis
Anaphylaxis is defined as "a serious allergic reaction that is rapid in onset and may cause death". It typically results in a number of symptoms including throat swelling, an itchy rash, and low blood pressure...
, and urticaria
Urticaria
Urticaria is a kind of skin rash notable for pale red, raised, itchy bumps. Hives is frequently caused by allergic reactions; however, there are many non-allergic causes...
in some cases. Patients typically react to other NSAIDS
Non-steroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs, but also referred to as nonsteroidal anti-inflammatory agents/analgesics or nonsteroidal Anti-inflammatory medicines , are drugs with analgesic and antipyretic effects and which have, in higher doses, anti-inflammatory...
such as ibuprofen
Ibuprofen
Ibuprofen is a nonsteroidal anti-inflammatory drug used for relief of symptoms of arthritis, fever, as an analgesic , especially where there is an inflammatory component, and dysmenorrhea....
, although paracetamol
Paracetamol
Paracetamol INN , or acetaminophen USAN , is a widely used over-the-counter analgesic and antipyretic . It is commonly used for the relief of headaches and other minor aches and pains and is a major ingredient in numerous cold and flu remedies...
(known as acetaminophen in the United States) is generally considered safe.
Anosmia
Anosmia
Anosmia is a lack of functioning olfaction, or in other words, an inability to perceive odors. Anosmia may be either temporary or permanent. A related term, hyposmia, refers to a decreased ability to smell, while hyperosmia refers to an increased ability to smell. Some people may be anosmic for one...
(lack of smell) is also typical, as the inflammation reaches the olfactory receptors in the nose.
Cause
The disorder is caused by an anomaly in the arachidonic acidArachidonic acid
Arachidonic acid is a polyunsaturated omega-6 fatty acid 20:4.It is the counterpart to the saturated arachidic acid found in peanut oil, Arachidonic acid (AA, sometimes ARA) is a polyunsaturated omega-6 fatty acid 20:4(ω-6).It is the counterpart to the saturated arachidic acid found in peanut oil,...
cascade, which causes undue production of leukotrienes, a series of chemicals involved in the body's inflammatory response. When prostaglandin
Prostaglandin
A prostaglandin is any member of a group of lipid compounds that are derived enzymatically from fatty acids and have important functions in the animal body. Every prostaglandin contains 20 carbon atoms, including a 5-carbon ring....
production is blocked by NSAIDS like aspirin, the cascade shunts entirely to leukotrienes, causing overproduction of LT-4 and producing the severe allergy-like effects.
There may be a relationship between aspirin-induced asthma and TBX21
TBX21
T-box transcription factor TBX21 is a protein that in humans is encoded by the TBX21 gene....
, PTGER2, and LTC4S.
In addition to aspirin, other vaso-dilators may induce the same reaction, such as alcohol.
Medication
The preferred treatment now is desensitization to aspirin, undertaken at a clinic specializing in such treatment. Patients who are desensitized then take a maintenance dose of aspirin daily; they have reduced need for supporting medications and fewer asthma and sinusitis symptoms than previously; many have an improved sense of smell.Treatment formerly focused on relieving the symptoms. Even desensitized people may continue to use nasal steroids, inhaled steroids, and leukotriene
Leukotriene
Leukotrienes are fatty signaling molecules. They were first found in leukocytes . One of their roles is to trigger contractions in the smooth muscles lining the trachea; their overproduction is a major cause of inflammation in asthma and allergic rhinitis...
antagonists.
Leukotriene antagonists and inhibitors (montelukast
Montelukast
Montelukast is a leukotriene receptor antagonist used for the maintenance treatment of asthma and to relieve symptoms of seasonal allergies. It is usually administered orally...
, zafirlukast
Zafirlukast
Zafirlukast is an oral leukotriene receptor antagonist for the maintenance treatment of asthma, often used in conjunction with an inhaled steroid and/or long-acting bronchodilator. It is available as a tablet and is usually dosed twice daily. Another leukotriene receptor antagonist is montelukast...
, and zileuton
Zileuton
Zileuton is an orally active inhibitor of 5-lipoxygenase, and thus inhibits leukotrienes formation. Zileuton is used for the maintenance treatment of asthma. Zileuton was introduced in 1996 by Abbott Laboratories and is now marketed in two formulations by Cornerstone Therapeutics Inc. under the...
) are helpful in treating Samter's.
Some patients require oral steroids to alleviate asthma and congestion, and most patients will have recurring or chronic sinusitis due to the nasal inflammation. Desensitization reduces the chance of recurrence.
Surgery
Occasionally surgery may be required to remove polyps, although they typically recur, particularly if desensitization is not undertaken.Diet
A diet low in omega-6 oilsOmega-6 fatty acid
n−6 fatty acids are a family of unsaturated fatty acids that have in common a final carbon–carbon double bond in the n−6 position, that is, the sixth bond, counting from the methyl end.The biological effects of the n−6 fatty acids are largely mediated by their conversion to n-6 eicosanoids...
(precursors of arachidonic acid), and high in omega-3 oils
Omega-3 fatty acid
N−3 fatty acids are essential unsaturated fatty acids with a double bond starting after the third carbon atom from the end of the carbon chain....
, may also help.
Some people find relief of symptoms by following a low-salicylate diet such as the Feingold diet
Feingold diet
The Feingold diet is a food elimination program developed by Ben F. Feingold, MD to treat hyperactivity. It eliminates a number of artificial colors and artificial flavors, aspartame, three petroleum-based preservatives, and certain salicylates. There has been much debate about the efficacy of...
. They may need to eliminate the other salicylate-containing foods identified by Swain in 1985 as well. For those who need them, these salicylates are listed in charts in the Feingold Handbook based on level of salicylate measured in the item. Unfortunately, any such list is only a rough guideline since amounts will vary depending on fruit/vegetable variety and where grown; in fact, organic foods have been shown to contain more salicylate than conventional produce because the plant is more likely to be under attack from pests, and salicylate is produced by the plant as protection.
Alternate and related names
Samter's triad goes by several other names:- Acetylsalicylic acid triad
- Widal's triad
- Francis' triad
- Aspirin triad
"AERD" ("aspirin-exacerbated respiratory disease") adds chronic rhinosinusitis to the triad. Similarly, "AIAR" ("aspirin-induced asthma and rhinitis") by definition includes rhinitis
Rhinitis
Rhinitis , commonly known as a stuffy nose, is the medical term describing irritation and inflammation of some internal areas of the nose. The primary symptom of rhinitis is nasal dripping. It is caused by chronic or acute inflammation of the mucous membrane of the nose due to viruses, bacteria or...
.
A sufferer who has not yet experienced asthma or aspirin sensitivity might be diagnosed as having:
- Non-allergic rhinitis
- Non-allergic rhinitis with eosinophilia syndrome (NARES)
History
It is named for Max SamterMax Samter
Max Samter was an immunologist who first identified the triad between asthma, aspirin sensitivity, and nasal polyps .- References :...
.
Initial reports on the link between asthma, aspirin and nasal polyposis were made by Widal in 1922. Further studies were done by Samter & Beers in reports published in 1968.