Month: August 2017

Eosinophilic Esophagitis

Definition:

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition caused by the abnormal accumulation of eosinophils (a type of white blood cell) in the lining of the tube carrying food from the throat to the stomach (i.e., esophagus).

Cause:

EoE is a relatively newly discovered condition and is being diagnosed with increasing frequency in the past decade in all age groups.  Though the exact cause of the condition is still being investigated, food and environmental allergies are suspected to play a role as it is often associated with other atopic disorders like seasonal allergies (i.e., allergic rhinitis), asthma, and eczema (i.e., atopic dermatitis).  Both genetic and environmental factors are theorized to contribute to this condition.

Mechanism:

Eosinophils release various proteins that cause damage to the structure of the esophagus resulting in ridges, furrows, scarring, and narrowing of the lumen of the tube.

Symptoms:

Children:

  1. Irritability
  2. Feeding difficulties
  3. Failure to thrive
  4. Vomiting
  5. Abdominal pain

Adults:

  1. Difficulty in swallowing (particularly solid foods)
  2. Heartburn/indigestion
  3. Pain or discomfort of the chest
  4. Abdominal pain in the upper abdomen

Diagnosis:

  1. Upper gastrointestinal endoscopy and biopsy: A flexible tube with a light source and a tiny camera (i.e., endoscope) is passed through the mouth down through the esophagus and the lining of the esophagus is closely examined.  A small piece of the lining is biopsied and examined under a microscope.  Accumulation of eosinophils in the lining of the esophagus confirms of the diagnosis of EoE.
  2. Skin prick tests and/or blood tests to foods in order to rule out food allergies as a cause. This is often coupled with a food elimination diet.
  3. Skin patch tests in order to detect delayed hypersensitivity to foods.
  4. Skin tests to environmental allergens such as pollens, especially when the symptoms of EoE exhibit a seasonal pattern.

Management:

  1. Restriction of certain specific foods in the diet based on skin prick and/or patch test results.
  2. Empiric elimination diets starting with dairy, wheat, eggs, soy, peanuts, tree nuts, fish, and shellfish (preferably under the guidance of a dietician) and gradually reintroducing one food at a time while closely monitoring the symptoms and follow-up biopsies.
  3. Medications: There are currently no FDA approved medications specific to EoE, but the following medications are commonly employed in the treatment of the condition refractive to dietary management.
  4. In a subset of individuals with EoE called Proton pump inhibitor-responsive esophageal eosinophilia (i.e., PPI-REE), medications called proton pump inhibitors (i.e., PPI’s) are used to reduce acid secretion in the stomach. Medications in this category [e.g., omeprazole (Prilosec); esomeprazole (Nexium)] can greatly help in relieving the symptoms.
  5. Topical corticosteroids which are usually utilized in inhalers to treat asthma [e.g., fluticasone (Flovent); budesonide (Pulmicort)] can also be helpful in EoE when ingested in a slurry form. They can control the structural damage to the esophagus due to their anti-inflammatory properties.
  6. When the disease is more severe and non-responsive to topical medications, systemic corticosteroids (e.g., prednisone, prednisolone, methylprednisolone) may be needed for a short duration.
  7. Newer anti-inflammatory drugs and biologicals are being researched in clinical trials at this time and may be available in the near future.
  8. In cases of severe narrowing of the esophagus, a procedure to dilate the esophagus by breaking up the strictures may help in relieving swallowing difficulties.

EoE is a complex immune system disorder with a chronic and relapsing course that has no known cure at this time.  Optimal management of the condition requires coordinated care by an experience board certified allergist, gastroenterologist, and nutritionist/dietician.

The board certified allergists at Black & Kletz Allergy will readily respond to your needs for further information and services in dealing with EoE and other allergic and immunologic disorders.  The allergy specialists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We offer on-site parking at all of our offices and our Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To make an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond to your inquiry within 24 hours by the next business day.  Black & Kletz Allergy treats both children and adults and we strive to provide the best and most current diagnostic and treatment modalities in the Washington, DC metro area, as we have done for more than 50 years.

Ragweed Allergies

It is August in the Washington, DC metropolitan area and to many allergy sufferers, that means ragweed pollen is in the air.  Ragweed is a flowering plant that releases its pollen into the air in the Washington, DC, Northern Virginia, and Maryland metro area usually beginning in mid-August and lasting until the end of October when the first frost occurs.  Recent studies show that with the rising temperatures and rising carbon dioxide (CO₂) levels, the ragweed season is now longer and may begin as early as early August.  Ragweed pollen is a major allergen to many allergic individuals that suffer from hay fever (i.e., allergic rhinitis) and is the number one cause of pollen-induced allergic rhinitis in North America.  Each ragweed plant can generate approximately 1 billion grains of ragweed pollen each season.  The ragweed pollen, like other pollens, is transported by the wind.  The wind causes the ragweed to become airborne for days which provides individuals an easy way to become exposed and thus sensitized to the ragweed pollen.  Ragweed pollen, like other pollens, can travel hundreds of miles due to its light weight.  The ragweed pollen count is lowest in the early morning and tends to peak in the midday.  Once sensitized, a person may exhibit the typical hay fever symptoms when exposed during the ragweed season.

What are the symptoms of ragweed allergy?

The classic symptoms of ragweed allergy may include all or any of the following:  runny nose, itchy nose, sneezing, post-nasal drip, nasal congestion, itchy throat, snoring, itchy ears, clogged ears, itchy eyes, watery eyes, red eyes, puffy eyes, sinus congestion, sinus headaches, fatigue, wheezing, coughing, chest tightness, and/or shortness of breath.  Complications of ragweed allergies may include sinus infectionsasthma exacerbations, ear infections, nasal polyps, Eustachian tube dysfunction, inability to concentrate, and sleep disturbances.

What can be done to avoid exposure to ragweed pollen?

Unfortunately, it is almost impossible to avoid exposure to ragweed pollen if you live in the Washington, DC metro area.  In fact, it is almost impossible to avoid no matter where you live in the U.S.  That being said, there are some measures that can be followed to minimize one’s exposure to ragweed pollen.  They are as follows:

  1. Keep the windows and doors closed in your automobiles and home.
  2. Stay indoors as much as possible during the ragweed season, especially from the late morning through the late afternoon when the ragweed pollen count is at its highest.
  3. Check the daily pollen count by clicking Today’s Pollen Count on our website above.
  4. Use air conditioning in both your automobiles and home.
  5. Use and change the air filters in your home and automobiles.
  6. When coming inside after being outdoors for a prolonged period of time, change your clothes.
  7. Take a shower before going to sleep at night to remove pollen.
  8. Do not hang your clothes to dry outdoors on a clothes line, as it will collect pollen.
  9. Wash your pet if the come indoors after a long period of time, as their fur acts as a carrier for pollen.
  10. Use a HEPA filter in each room of your home, or at least the rooms that you use most often

What medications can be used to alleviate symptoms?

There are a wide variety of over the counter (OTC) medications that can be utilized to help treat the symptoms of allergic rhinitis caused by ragweed.  Using nasal irrigation with saline can be very beneficial for most individuals to help reduce the nasal symptoms of ragweed allergy.  Oral antihistamines, nasal corticosteroids, nasal antihistamines, oral decongestants, anticholinergic agents, eye drops, and/or leukotriene antagonists are frequently used by board certified allergists like the ones at Black & Kletz Allergy to help prevent and manage hay fever symptoms.  For asthma symptoms that are caused by ragweed, a variety of medications are commonly used.  Some of these include inhaled corticosteroids, long-acting beta₂-agonists (in combination with inhaled corticosteroids), leukotriene antagonists, inhaled beta₂-adrenergic agonists, oral beta₂-adrenergic agonists, and xanthine derivatives.  Xolair (i.e., (omalizumab) and Nucala (i.e., mepolizumab) are injectable medications that are used to treat more difficult cases of perennial asthma, where the asthma is more chronic.

Are allergy shots helpful?

Absolutely yes.  Allergy shots (i.e., allergy immunotherapy, allergy injections, allergy desensitization) are very helpful.  Allergy shots have been around for more than 100 years in the U.S.  They are generally given to individuals of any age above the age of 2, and they can be continued in pregnant individuals, as long as it is approved by the individual’s Ob/Gyn doctor.  They are effective in 80-85% of individuals and the average length of time on allergy shots is 3-5 years.  They work by making the individual tolerant to whatever is put into their allergy serum (e.g., ragweed, trees, grasses, dust mites, molds, cats, dogs).

Where can I get help with my allergies?

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating ragweed allergy for more than 50 years in the Washington, DC, Northern, VA, and Maryland metropolitan area.  Black & Kletz Allergy also treats allergies to other environmental triggers (e.g., trees, grasses, dust mites, cats, dogs, horses, rodents, cockroaches), medications, foods, insect stings, poison ivy, poison sumac, and poison oak.  We also treat hives (i.e., urticaria)swelling episodes (i.e., angioedema)generalized itching (i.e., pruritus)immunological disordersmammalian meat allergysinus disorders (e.g., sinus infections), eosinophilic esophagitiseczema (i.e., atopic dermatitis), contact dermatitis, nasal polyps, latex allergies, and anaphylaxis.

Black & Kletz Allergy has 3 convenient office locations:  Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer on-site parking.  The Washington, DC and McLean, VA locations are Metro accessible and there is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To make an appointment, please call us or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy is dedicated to providing quality cutting edge allergy, asthma, and immunologic care to the residents and visitors of the Washington, DC metro area, as we have done for more than a half century.