ORIGINAL ARTICLE
Impact of vitamin D deficiency upon clinical presentation in nasal polyposis Rodney J. Schlosser, MD1,2 , Zachary M. Soler, MD2 , Gregg W. Schmedes, MD2 , Kristina Storck, MSPH2 and Jennifer K. Mulligan, PhD1,2,3
Background: The objective of this work was to determine if specific chronic rhinosinusitis with nasal polyps (CRSwNP) populations are at risk for vitamin D3 (VD3 ) deficiency and if VD3 levels correlate with radiographic measures of disease severity or eosinophilia.
sufficient VD3 levels. Lower VD3 levels also correlated with more severe mucosal disease on CT scans as measured by LMS. There was no correlation between VD3 levels and age, gender, body mass index, atopy, asthma, or CRSwNP subtype.
Methods: This study was a retrospective review of an academic rhinology practice. CRSwNP patients who had VD3 levels and CT scan within 6 months of each other were included. CT scans were graded using Lund-Mackay scoring (LMS) and peripheral eosinophil counts were measured. Demographic data including race, gender, age, body mass index, atopic status, and presence of asthma were collected. CRSwNP was subdivided into allergic fungal rhinosinusitis (AFRS), aspirin-exacerbated respiratory disease (AERD), and other CRSwNP. Multivariate analysis was performed to examine correlations and control for confounding factors.
Conclusion: VD3 insufficiency/deficiency is common in CRSwNP patients, especially those of African American race. Lower levels of VD3 are associated with worse LMS on CT. The role of VD3 in CRSwNP warrants further investigation.
Results: Insufficient VD3 levels were found in 55% of all CRSwNP patients. VD3 correlated with African American race because nearly 80% of all African Americans had in-
C
hronic rhinosinusitis with nasal polyposis (CRSwNP) is 1 of the most difficult forms of CRS to treat. It is likely that some combination of aberrant host immune response to a variety of environmental exposures results in the development of a local eosinophilic, T-helper 2 (Th2) skewed microenvironment.1
1 Department
of Surgery, Ralph H. Johnson VA Medical Center, Charleston, SC; 2 Division of Rhinology & Sinus Surgery, Department of Otolaryngology, Medical University of South Carolina, Charleston, SC; 3 Department of Pediatrics, Division of Neonatology, Medical University of South Carolina, Charleston, SC Correspondence to: Rodney J. Schlosser, MD, Division of Rhinology & Sinus Surgery, Department of Otolaryngology, Medical University of South Carolina, 135 Rutledge Avenue, MSC 550, Charleston, SC 29425; [email protected] Funding sources for the study: Flight Attendant Medical Research Institute and VA Merit grants (both to R.J.S.). Potential conflict of interest: None provided. Received: 11 October 2013; Revised: 26 November 2013; Accepted: 5 December 2013 DOI: 10.1002/alr.21274 View this article online at wileyonlinelibrary.com.
C 2014 ARS-AAOA, LLC.
Key Words: nasal polyposis; vitamin D; sinusitis; chronic rhinosinusitis; polyps; vitamin D deficiency; cholecalciferol How to Cite this Article: Schlosser RJ, Soler ZM, Schmedes GW, Storck K, Mulligan JK. Impact of vitamin D deficiency upon clinical presentation in nasal polyposis. Int Forum Allergy Rhinol. 2014;4:196–199.
Vitamin D3 (VD3 ) is a potent immunomodulatory steroid hormone involved in the regulation of a variety of cell types that play a role in the local immune response, and increasing evidence suggests VD3 may be involved in other Th2-skewed airway disorders. Lower VD3 levels have been associated with increased likelihood of being hospitalized for asthma-related complications and increased use of antiinflammatory medications.2 Data from the Third National Health and Nutrition Examination Survey showed that low VD3 levels are associated with impaired pulmonary function tests and recent upper respiratory tract infections, with an even stronger correlation in patients with asthma and chronic obstructive pulmonary disease.3 In CRS, African Americans have been reported to have lower VD3 levels than white patients; however, the type of CRS was not reported.4 A prior study by our group found that children and adults with nonatopic CRSwNP and allergic fungal rhinosinusitis (AFRS) had lower VD3 levels than patients with chronic rhinosinusitis without nasal polyps (CRSsNP) and a control group. Immunologically, VD3 levels inversely correlate with numbers of circulating and local
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Vitamin D and nasal polyposis
mature dendritic cells (DCs) and DC regulatory factors.5, 6 Clinically, this study also found that in AFRS, VD3 deficiency correlated with increased bone erosion on computed tomography (CT). The goals of this study were to (1) determine whether specific CRSwNP populations are at risk for VD3 deficiency; and (2) determine if VD3 levels correlate with clinical measures of severity, to include radiographic measures of mucosal inflammation and eosinophilia.
Patients and methods This study was performed with approval of the Institutional Review Board (HR 19548 and 14124) for Human Research at Medical University of South Carolina (MUSC). A review was performed of all CRSwNP patients seen at the MUSC Sinus Center from January 2010 to February 2013 who met the following inclusion criteria: diagnosis of CRSwNP,7 serum 25 hydroxyvitamin D3 (25VD3 ) level, and CT scan within 6 months of each other. The Lund-Mackay scoring (LMS) system7 was used to measure mucosal inflammation on CT by a reviewer blinded to all other clinical data. Although this scoring system is the most widely used, it does not account for previous surgery. Prior to obtaining CT scans, all patients were treated with broad spectrum oral antibiotics, intranasal steroid spray, saline irrigations, and oral steroids if tolerated. Demographic factors were collected, including age, race, gender, body mass index (BMI), and presence of asthma or atopy. Atopic status was determined by either a positive skin-prick test or elevated serum specific immunoglobulin E (IgE) levels. CRSwNP was classified as allergic fungal rhinosinusitis (AFRS), asthma-exacerbated respiratory disease (AERD), or other CRSwNP. AFRS patients met classic Bent-Kuhn criteria.8 Absolute eosinophil count and serum eosinophil percentage were also analyzed when available. 25VD3 levels were drawn and measured at the Medical University of South Carolina Department of Laboratory Services using liquid chromatography/tandem mass spectrometry. Levels
Impact of vitamin D deficiency upon clinical presentation in nasal polyposis Rodney J. Schlosser, MD1,2 , Zachary M. Soler, MD2 , Gregg W. Schmedes, MD2 , Kristina Storck, MSPH2 and Jennifer K. Mulligan, PhD1,2,3
Background: The objective of this work was to determine if specific chronic rhinosinusitis with nasal polyps (CRSwNP) populations are at risk for vitamin D3 (VD3 ) deficiency and if VD3 levels correlate with radiographic measures of disease severity or eosinophilia.
sufficient VD3 levels. Lower VD3 levels also correlated with more severe mucosal disease on CT scans as measured by LMS. There was no correlation between VD3 levels and age, gender, body mass index, atopy, asthma, or CRSwNP subtype.
Methods: This study was a retrospective review of an academic rhinology practice. CRSwNP patients who had VD3 levels and CT scan within 6 months of each other were included. CT scans were graded using Lund-Mackay scoring (LMS) and peripheral eosinophil counts were measured. Demographic data including race, gender, age, body mass index, atopic status, and presence of asthma were collected. CRSwNP was subdivided into allergic fungal rhinosinusitis (AFRS), aspirin-exacerbated respiratory disease (AERD), and other CRSwNP. Multivariate analysis was performed to examine correlations and control for confounding factors.
Conclusion: VD3 insufficiency/deficiency is common in CRSwNP patients, especially those of African American race. Lower levels of VD3 are associated with worse LMS on CT. The role of VD3 in CRSwNP warrants further investigation.
Results: Insufficient VD3 levels were found in 55% of all CRSwNP patients. VD3 correlated with African American race because nearly 80% of all African Americans had in-
C
hronic rhinosinusitis with nasal polyposis (CRSwNP) is 1 of the most difficult forms of CRS to treat. It is likely that some combination of aberrant host immune response to a variety of environmental exposures results in the development of a local eosinophilic, T-helper 2 (Th2) skewed microenvironment.1
1 Department
of Surgery, Ralph H. Johnson VA Medical Center, Charleston, SC; 2 Division of Rhinology & Sinus Surgery, Department of Otolaryngology, Medical University of South Carolina, Charleston, SC; 3 Department of Pediatrics, Division of Neonatology, Medical University of South Carolina, Charleston, SC Correspondence to: Rodney J. Schlosser, MD, Division of Rhinology & Sinus Surgery, Department of Otolaryngology, Medical University of South Carolina, 135 Rutledge Avenue, MSC 550, Charleston, SC 29425; [email protected] Funding sources for the study: Flight Attendant Medical Research Institute and VA Merit grants (both to R.J.S.). Potential conflict of interest: None provided. Received: 11 October 2013; Revised: 26 November 2013; Accepted: 5 December 2013 DOI: 10.1002/alr.21274 View this article online at wileyonlinelibrary.com.
C 2014 ARS-AAOA, LLC.
Key Words: nasal polyposis; vitamin D; sinusitis; chronic rhinosinusitis; polyps; vitamin D deficiency; cholecalciferol How to Cite this Article: Schlosser RJ, Soler ZM, Schmedes GW, Storck K, Mulligan JK. Impact of vitamin D deficiency upon clinical presentation in nasal polyposis. Int Forum Allergy Rhinol. 2014;4:196–199.
Vitamin D3 (VD3 ) is a potent immunomodulatory steroid hormone involved in the regulation of a variety of cell types that play a role in the local immune response, and increasing evidence suggests VD3 may be involved in other Th2-skewed airway disorders. Lower VD3 levels have been associated with increased likelihood of being hospitalized for asthma-related complications and increased use of antiinflammatory medications.2 Data from the Third National Health and Nutrition Examination Survey showed that low VD3 levels are associated with impaired pulmonary function tests and recent upper respiratory tract infections, with an even stronger correlation in patients with asthma and chronic obstructive pulmonary disease.3 In CRS, African Americans have been reported to have lower VD3 levels than white patients; however, the type of CRS was not reported.4 A prior study by our group found that children and adults with nonatopic CRSwNP and allergic fungal rhinosinusitis (AFRS) had lower VD3 levels than patients with chronic rhinosinusitis without nasal polyps (CRSsNP) and a control group. Immunologically, VD3 levels inversely correlate with numbers of circulating and local
International Forum of Allergy & Rhinology, Vol. 4, No. 3, March 2014
196
Vitamin D and nasal polyposis
mature dendritic cells (DCs) and DC regulatory factors.5, 6 Clinically, this study also found that in AFRS, VD3 deficiency correlated with increased bone erosion on computed tomography (CT). The goals of this study were to (1) determine whether specific CRSwNP populations are at risk for VD3 deficiency; and (2) determine if VD3 levels correlate with clinical measures of severity, to include radiographic measures of mucosal inflammation and eosinophilia.
Patients and methods This study was performed with approval of the Institutional Review Board (HR 19548 and 14124) for Human Research at Medical University of South Carolina (MUSC). A review was performed of all CRSwNP patients seen at the MUSC Sinus Center from January 2010 to February 2013 who met the following inclusion criteria: diagnosis of CRSwNP,7 serum 25 hydroxyvitamin D3 (25VD3 ) level, and CT scan within 6 months of each other. The Lund-Mackay scoring (LMS) system7 was used to measure mucosal inflammation on CT by a reviewer blinded to all other clinical data. Although this scoring system is the most widely used, it does not account for previous surgery. Prior to obtaining CT scans, all patients were treated with broad spectrum oral antibiotics, intranasal steroid spray, saline irrigations, and oral steroids if tolerated. Demographic factors were collected, including age, race, gender, body mass index (BMI), and presence of asthma or atopy. Atopic status was determined by either a positive skin-prick test or elevated serum specific immunoglobulin E (IgE) levels. CRSwNP was classified as allergic fungal rhinosinusitis (AFRS), asthma-exacerbated respiratory disease (AERD), or other CRSwNP. AFRS patients met classic Bent-Kuhn criteria.8 Absolute eosinophil count and serum eosinophil percentage were also analyzed when available. 25VD3 levels were drawn and measured at the Medical University of South Carolina Department of Laboratory Services using liquid chromatography/tandem mass spectrometry. Levels
