Fatal consequence of allergic rhinitis

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To the Editor:

Although it is accepted that allergic rhinitis significantly affects quality of life, it can also have tragic consequences. Our patient was a 43-year-old woman who was referred for allergy evaluation. Eight months before the consult, she had a sneezing episode with closing of her eyes while driving at 40 miles per hour with her daughter and crashed into another vehicle, killing the other driver. She sustained ankle and foot fractures.

Since childhood, she had been having sudden, severe episodic “fits” of 3 to 5 sneezes in a row associated with closing of the eyes occurring about once a week and sometimes triggered by increased dust and wind exposure. The sneezing episodes were acute isolated incidents with no associated acute or chronic nasal congestion, nasal itching, rhinorrhea, or eye symptoms, and therefore she did not consider allergic rhinitis or hay fever and believed she had a hereditary condition she shared with her father. On physical examination, she had mild nasal congestion with no rhinorrhea. Skin testing showed very large (average wheal diameter, 20-30 mm) reactions to all grass pollen, sycamore tree, Russian thistle, and cat.

Most driving accidents and injuries have been associated with the adverse effects of sedating anthistamines,¹ but in this case the actual symptoms of allergic rhinitis were the immediate cause.

Sneezing is initiated by the trigeminal nerve in the nasal epithelium and accompanied by reflex closing of the eyes and occasionally cardiovascular reflexes, such as bradycardia. These reflexes are likely protective responses against irritants.² A rare condition in patients with no evidence of rhinitis is the photic sneeze reflex, which is an autosomal dominant trait with an unknown mechanism characterized by sneezing triggered by bright light or sunshine.³

We did not find any reports in the medical literature of sneezing-related accidents. An insurance industry–sponsored research study from the United Kingdom claims that in excess of 2 million United Kingdom motorists (7%) have had an accident or near miss or momentarily lost control of their car as a result of sneezing while driving.⁴ There are no statistics from federal or state authorities regarding sneezing-related accidents. However, a National Highway and Traffic Safety Administration (NHTSA) report does mention that at least 1 reporting authority includes “sneezing/coughing/itching” as a category of driver distraction.⁵

In this case the patient had unrecognized and untreated allergic rhinitis confirmed by mean of skin testing. In our area many allergists have anecdotal reports of accidents or near accidents caused by sneezing while driving. We are reporting this case to highlight the need to recognize and warn patients of potentially very serious consequences of uncontrolled allergic rhinitis.

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References 

1. Verster JC, Volkerts ER. Antihistamines and driving ability: evidence from on-the-road driving studies during normal traffic. Ann Allergy Asthma Immunol. 2004;92:294–303
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2. Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(suppl):S1–S84
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3. Whitman BW, Packer RJ. The photic sneeze reflex: literature review and discussion. Neurology. 1993;43:868–871
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4. Esure Insurance Co–sponsored online research study (conducted by MyVoice), February 2008. Results available at: www.esure.com. Accessed June 18, 2010.
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5. National Highway Traffic Safety Administration (NHTSA). Driver distraction: a review of the current state-of-knowledge. Washington (DC): National Highway Traffic Safety Administration; 2008;Publication no. DOT HS 810 787
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