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Mammalian Meat Allergy Update

Mammalian meat allergy which is also known as alpha-gal syndrome causes an immediate hypersensitivity reaction hours after eating beef, pork, lamb, venison, or any other mammalian meat product. Although the allergy was first described in patients with hives (i.e., urticaria) and severe life-threatening reactions such as anaphylaxis, there is now a new phenotype of mammalian meat allergy that has different presenting symptoms. The new and increasingly recognized phenotype is called gastrointestinal (GI) alpha-gal. Gastrointestinal alpha-gal presents with GI symptoms such as abdominal pain, diarrhea, nausea, and vomiting without the predominant skin, respiratory, or circulatory symptoms.

Individuals with mammalian meat allergy or alpha-gal syndrome have an allergy to the galactose alpha-1,3-galactose, a sugar molecule on the cells of all non-primate mammals which is not present in humans. Lone star ticks can transfer this molecule to humans, by first feeding the mammals, and subsequently biting the humans. Since the galactose alpha-1,3-galactose molecule is foreign to humans, antibodies are formed in order to fight the foreign sugar molecule. When this occurs, the individual becomes sensitized to the molecule. The antibodies produced are called IgE antibodies that are specific towards the galactose alpha-1,3-galactose sugar molecule.

After the sensitization to the galactose alpha-1,3-galactose sugar molecule occurs, if the individual eats mammalian meat which naturally contains the galactose alpha-1,3-galactose (i.e., alpha-gal antigen), the alpha-gal antigen binds to the IgE antibodies present on the mast cells that richly populate the GI tract. As a result of the binding, these mast cells degranulate and release large quantities of histamine and other chemical mediators into the bloodstream. These chemical mediators in turn can act on sensory nerve endings to cause pain, intestinal smooth muscles to cause contractions, and/or mucous glands to cause the secretion of mucous.

When patients seek care for frequent abdominal pain, bloating, cramping, and/or diarrhea, they are often diagnosed as having irritable bowel syndrome (IBS), if no organic cause for these symptoms is identified. Some of these patients could have been previously sensitized to alpha-gal and their symptoms could be an indicator of an allergic reaction. The onset of symptoms could be several hours after the ingestion of the mammalian meat, as opposed to other common immediate type of hypersensitivity reaction (e.g., egg allergy, peanut allergy, seafood allergy), where symptoms usually begin within minutes of the exposure to the food.

A history of awakening up at night from sleep with gastrointestinal distress may suggest alpha-gal given the typical hours delay that occurs in this condition from alpha-gal ingestion to the subsequent reaction. Patients who have a history of tick bites or enjoy outdoor pursuits are at a higher risk for this allergy.


Alpha-gal syndrome or mammalian meat allergy is a clinical diagnosis with supporting laboratory findings (i.e., a positive alpha-gal antibody level in the blood). A diagnosis of alpha-gal syndrome may be made in patients with consistent symptoms and an increased alpha-gal IgE titer whose symptoms resolve or improve after adhering to an alpha-gal–avoidance diet, where mammalian meat is avoided.

The clinical presentation of this syndrome can be highly variable and unpredictable. Many patients who have been are previously sensitized, may not have symptoms every time they consume mammalian meat. At other times however, they can have a severe reaction after consuming even a small quantity of mammalian meat.

It should be noted that the gold standard for diagnosing food allergies typically is by an oral food challenge. In individuals with mammalian meat allergy however, there is usually at least a couple or more hours-long delay time until the allergic reaction occurs. Since the allergic reaction is delayed and may also be inconsistent, an oral food challenge is not reliable and thus not used to diagnose mammalian meat allergy.


The cornerstone of managing alpha-gal syndrome is to eliminate alpha-gal from the diet. Individuals diagnosed with this condition should not eat pork, beef, lamb, venison, rabbit, whale, or any other mammalian meat. In essence, any animal with hair as well as products made from these mammals (e.g., lard, butter, milk) should be avoided. Dairy does contain smaller amounts of alpha-gal, particularly ice cream, cream, and cream cheese, which have a high fat content.

Gelatin is derived from the collagen in pig or cow bones. As such, foods that contain gelatin (e.g., marshmallows, gummy bears, gelatin candies) also may trigger allergic reactions. In addition, processed foods can have small amounts of animal-derived products. Restaurants may cross-contaminate foods with alpha-gal which may be a problem for patients with high levels of sensitivity to alpha-gal.

Fish, shellfish, turkey, chicken, and other fowl are acceptable for patients with alpha-gal.


Alpha-gal–allergic individuals should take measures to avoid further tick bites because additional tick bites may worsen the allergy. Performing regular tick checks, showering soon after activities in grassy and woody areas, creating a barrier at the ankles by pulling up tight mesh socks over the pant cuffs on hikes, and treating clothes and boots with permethrin may all help reduce the likelihood of tick bites.

Certain medications such as cetuximab (i.e., Erbitux) and pancreatic enzymes are derived from pigs and may cause problems in mammalian meat-allergic individuals. A company in Blacksburg, VA developed alpha-gal-free pork, which is FDA-approved but not yet widely available. Another option for alpha-gal allergic individuals is to consume plant-based alternatives to meat commonly found in companies like Beyond Meat or Impossible (e.g., Impossible burger).

All patients diagnosed with alpha-gal allergy should carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) for use in case of a systemic reaction following an inadvertent exposure to mammalian meat. If a self-injectable epinephrine device is used, the patient should go immediately to the closest emergency room.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating food allergies and intolerances as well as mammalian meat allergy (i.e., alpha-gal) for many years. If you or your child suffers from food allergies, food intolerances, eosinophilic esophagitis, hives (i.e., urticaria), swelling episodes (i.e., angioedema) please call us to make an appointment. Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas with on-site parking all 3 locations. Our Washington, DC and McLean, VA locations are Metro accessible and we offer a free shuttle between our McLean, VA office and the Spring Hill metro station on the silver line. We look forward to helping you with all your allergy, asthma, and immunology needs as we have been doing in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than a half century.

Poison Ivy, Poison Oak, and Poison Sumac Update

It is the Spring now and people will be spending a lot more time outdoors. Activities such as hiking, gardening, landscaping, golf, and picnicking tend to pick up in the Spring when the temperatures are warmer and these activities are generally enjoyed until the late Fall in the Washington, DC, Northern Virginia, and Maryland metropolitan area, when the temperatures become cooler. These outdoor activities as well as other outside happenings may predispose an individual to coming in contact with poison ivy, poison oak, and/or poison sumac. These plants are well known for causing an itchy rash when the plants come in contact with a sensitive individual. The itchy rash can occur from touching any part of the plant including the leaves, berries, flowers, stems, and/or roots, whether the plant is living or dead.  In some individuals, coming in close contact with anything that has touched the plants, (e.g., shoes, sneakers, clothing, garden tools, lawn mowers, fur from animals) can also spread the agent that is responsible for causing the itchy rash.

The agent responsible for causing the itchy rash is a chemical called urushiol. It is important to note that all parts of these 3 plants contain the same oily pale-yellow liquid resin called urushiol.  As stated above, it is this contact with the urushiol that is responsible for causing the rash.  When an urushiol-sensitive individual comes in contact with the urushiol, an allergic reaction takes place. This allergic reaction occurs on the skin which results in an itchy rash. The rash that is caused by poison ivy, poison oak, and/or poison sumac is classified as “contact dermatitis.”

The itching and rash can vary in severity from individual to individual and range from a mild rash to a severe rash. The symptoms of the cutaneous allergic reaction may include itching, linear red streaks (which characteristically follows a straight line pattern where the plant brushed up against the skin), red bumps of varying sizes, and/or blisters filled with fluid. Occasionally, the rash can become secondarily infected, which is usually due to scratching.  Rarely, an individual may be so highly sensitive that angioedema (i.e., swelling) of the throat, face, lips, eyes, and/or neck may occur. If this type of swelling occurs, it can manifest itself as difficulty swallowing and/or difficulty breathing which can be very serious as it may lead to unconsciousness.  Individuals who develop such severe reactions should go immediately to the closest emergency room for treatment.

Usually, the symptoms of poison ivy, poison oak, and/or poison sumac begin between 24-48 hours after contact with the plants.  Occasionally, it may take a longer period of time to develop symptoms, particularly if it is the first time that the individual has a reaction.  The rash typically lasts about 2-3 weeks in duration, but can persist much longer in some sensitive individuals.

A few common fallacies should be pointed out about poison ivy, poison oak, and poison sumac. First of all, this type of contact dermatitis does not actually spread by itself. In order to develop a rash, contact with the urushiol liquid is necessary. Thus, the only way the rash is transported to other areas of the skin would be from spreading the oily urushiol from one area to another by way of one’s fingers. It is actually the urushiol being transported from one area to another that causes the contact dermatitis to be visible in another location. It is not the leakage of the blister fluid that causes other areas of the skin to be involved because there is no urushiol in the blister fluid. One should also keep in mind that there are other skin diseases that may cause blistering. It is advised to see a board certified allergist or dermatologist if you have blistering of any kind.

Identifying the differences between poison ivy, poison oak, and poison sumac is not always that easy and clinically not that important. Poison ivy and poison oak look similar and consist of compound leaves (i.e., multiple leaflets that make up 1 leaf). In the case of poison ivy and poison oak, there a 3 leaflets on each leaf. Poison ivy has 3 glossy almond-shaped leaflets with jagged edges per leaf. In the Spring, the leaves can be red or a mixture of red and green. In the Summer, the leaves are green. In the Fall, the leaves can be bright orange, yellow, or red. Poison oak has 3 fuzzy leaflets per leaf that have uneven and scalloped edges. In the different seasons, the leaves can vary from green to red. Poison oak tends to blend in around the surrounding shrubs which often makes it difficult to spot. Poison sumac has between 7 and 13 leaflets on a reddish stem and resembles a fern. The green leaflets of poison sumac are oval-shaped with a pointy top. These leaflets tend to run in pairs up the stem. It should be noted that all 3 plants may also contain berries.

Prevention of contact with poison ivy, poison oak, and poison sumac is ideally the best way to avoid the contact dermatitis that occurs with these plants. It is advisable to wear long pants, long-sleeved shirts, sleeves, gloves, and closed shoes in order to decrease the probability of contracting the rash. It is also desirable to wash one’s clothes immediately in order to remove any urushiol that may have gotten on one’s clothing from the plants.

The treatment of poison ivy, poison oak, and/or poison sumac is to wash the affected skin with a mild soap and cool water in order to try to remove the oily urushiol. Calamine lotion, zinc oxide ointment, and oral antihistamines are used often to help relieve the annoying symptoms. Occasionally oral corticosteroids and antibiotics may be necessary in more severe and recalcitrant cases and in cases of secondary infections respectively. If the rash persists and or gets worse, it is important to see a board certified allergist or dermatologist.

The board certified allergy specialists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan region and have been providing allergy and asthma care to this area for more than 50 years. We diagnose and treat both adults and children. Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices offer on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. In addition, our McLean, VA office location offers a complementary shuttle that runs between this office and the Spring Hill metro station on the silver line. For an appointment, please call one of our offices. Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from poison ivy, poison oak, poison sumac, contact dermatitis, hives (i.e., urticaria) hay fever (i.e., allergic rhinitis), sinus problems, asthma, or immune issues, please contact our office as it is our mission to help alleviate your undesirable symptoms, so that you can enjoy a better quality of life.

SMART Asthma Therapy

Asthma is a chronic inflammatory disease of the airways that causes frequent symptoms of coughing, chest tightness, wheezing and/or shortness of breath.

If the symptoms are less frequent than twice a week during the daytime and less than twice a month during the nights, it is termed “intermittent” asthma. If the symptoms are more frequent than twice a week during the daytime and more than twice a month during the nights, it is called “persistent” asthma. Persistent asthma is further subdivided into mild, moderate, and severe based on the severity and frequency of the asthma symptoms as well as lung function measurements obtained by pulmonary function tests.

Intermittent asthma is traditionally treated with an as needed “rescue” inhaler medication, which is usually an albuterol (e.g., ProAir, Proventil, Ventolin) inhaler. Albuterol is a short-acting beta 2 agonist bronchodilator medication which acts as a dilator of the bronchial tubes of the lungs. It provides quick relief for the wheezing, chest tightness, coughing, and shortness of breath that plagues asthma sufferers. The usual dose is 2 puffs from the inhaler every 4 to 6 hours as needed for symptom relief. Albuterol can also be used prior to exertion for the prevention of exercise-induced asthma symptoms.

Persistent asthma, on the other hand, needs a daily scheduled maintenance medication in order to control the inflammation that occurs in asthmatics. The daily maintenance medication helps prevent symptoms and preserve the lung function in the long term. The maintenance medication usually consists of a corticosteroid in the form of an inhaler [Flovent (fluticasone), QVAR Redihaler (beclomethasone), Asmanex (mometasone), Pulmicort (budesonide), Arnuity (fluticasone), Alvesco (ciclesonide), Aerobid (flunisolide)] which is usually taken either once or twice a day. There is also another maintenance therapy that does not include a corticosteroid. Such non-steroid maintenance medications typically are known as leukotriene antagonists [e.g., Singulair (montelukast), Accolate (zafirlukast), Zyflo (zileuton)]. It is up to the allergist and patient to decide which type of maintenance therapy is best for that patient.

Since a maintenance medication is needed in most persistent asthmatic patients, usually 2 different types of inhalers are needed in total – one for the daily preventive maintenance and the other for the as needed quick relief for asthma symptoms. Though it is an effective way of treating asthma, it can sometimes lead to confusion for some patients, so it is necessary for the board certified allergist to explain how and when to use both types of medications.

There has been a recent update in the recommendations for asthma management from the National Asthma Education and Prevention Program. The newer guidelines recommend one inhaler both for prevention and rescue therapy. This new recommendation is termed Single Maintenance And Reliever Therapy (SMART).

The recommended inhaler contains a combination of a corticosteroid (anti-inflammatory agent) and a short-acting beta 2 agonist bronchodilator to open the airways quickly. In addition to using it once or twice a day on a regular daily basis for maintenance, the patient can take one or two puffs from the same inhaler as needed for the rapid relief of the symptoms. SMART therapy is approved for children who are 5 years old and above.

Clinical studies have shown that SMART therapy reduces acute flare-ups, emergency healthcare visits, and hospitalizations compared to the traditional therapy in patients with moderate and severe persistent asthma. However, If the patient’s current therapy is controlling their asthma well and they are not having side effects, there is no need to make a change.

There are 2 main corticosteroid medications recommended for SMART therapy: budesonide and mometasone. These 2 corticosteroids can be used as the preventive component. Formoterol is a faster acting long-acting beta 2 agonist that is used as the rescue component. Only formoterol-containing formulations should be used. Formoterol has a more rapid onset bronchodilator effect than other long-acting beta 2 agonists, similar to albuterol. Budesonide/formoterol (i.e., Symbicort) is the most commonly used formulation for SMART therapy, but mometasone/formoterol (i.e., Dulera) may also be used.

The board certified allergy specialists at Black & Kletz Allergy have been treating asthma in pediatric and adult patients for more than 5 decades. We have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area which are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 offices have on-site parking and the 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. If you or someone you know has asthma or any other allergic or immunologic condition, please make an appointment so that we may help you. Alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy have been treating patients in the Washington, DC metropolitan area for allergies, asthma, sinus disease, and immunologic disorders for more than 50 years. We would be pleased to provide allergy and asthma relief for you and your family in a relaxed, caring, and professional environment.

Hives, Itching, and Swelling

Of all the ailments that people seek an allergist’s care for, one of the most bothersome conditions is hives (i.e., urticaria). A hive can be described as an itchy red blotch or welt that can occur anywhere on the skin. A hive can be flush with the skin or it can be a raised bump. Usually, there are a multitude of hives that occur as opposed to just one hive, although a single hive may occur. The size and shape of a hive is variable as it can be large or small and it can take any shape. Although hives usually itch, they can occur without itching. Hives can also occur internally such as the gastrointestinal system. If the hives occur in the stomach, the individual may experience abdominal pain, abdominal cramping, nausea, and/or vomiting as a result of internal hives. If the hives occur in the throat, the person may feel a tightening of their throat.

There are 2 basic criteria for hives. If one has hives on and off for less than 6 weeks, that person is said to have “acute” urticaria. If, however, the hives last 6 or more weeks, that individual is said to have “chronic” urticaria. Acute urticaria is more common than chronic urticaria and it is not uncommon. Approximately 20-25% of Americans will have hives at some point in their lives. Hives generally last less than 24 hours, but may last longer. They may occur very frequently (i.e., multiple times a day) or occur very rarely, (i.e., one isolated episode). Hives tend to be intermittent (i.e., come and go) as opposed to remaining on the skin for days, weeks, or months like eczema (i.e., atopic dermatitis). Chronic urticaria acts the same as acute urticaria except that the duration of the hives is 6 weeks or greater.

There are many causes of hives. Some of the common causes of hives may include an allergy to a food (e.g., peanuts, tree nuts, milk, egg, soy, wheat, fish, shellfish), medication [e.g., antibiotic, aspirin, nonsteroidal anti-inflammatory drugs (ibuprofen (Advil, Motrin), naproxen (Naprosyn, Aleve, Anaprox), indomethacin (Indocin), salsalate (Disalcid), diclofenac (Arthrotec, Voltaren, Cataflam), ketorolac (Toradol), celecoxib (Celebrex), meloxicam (Mobic), nabumetone (Relafen), tolmetin (Tolectin), fenoprofen (Asaid), etodolac (Lodine), sulindac (Clinoril), piroxicam (Feldene), and oxaprozin (Daypro)], or flying insect sting (e.g., bee sting). Other common causes may include an infection (i.e., viral, bacterial, fungal, or parasitic), autoimmune disorders (i.e., the immune system fights against an individual’s body instead of fighting against outside invaders), inflammatory conditions (i.e., vasculitis), and/or rarely cancers. In addition to the forementioned causes, physical stimuli such as heat, cold, exercise, pressure, vibration, sun exposure, and/or even water exposure can cause hives in sensitive individuals.

If someone has chronic urticaria, it is important to find out if there is an underlying condition present that is causing that individual to have the hives. The diagnosis of hives begins with a comprehensive history and physical examination. Allergy skin testing or blood testing may be needed depending on the patient’s unique situation with respect to their hives. For patients with chronic urticaria, blood testing and a urinalysis are obtained in order to look for an underlying condition that may be causing the hives. It is interesting to note that despite doing a thorough workup for chronic urticaria with blood and urine tests, 95% of the time no cause is identified. In these cases, the chronic urticaria is designated as “idiopathic” which is basically saying that we know what is not causing the hives, but we still do not know what is causing them. These patients are labeled as having chronic idiopathic urticaria (CIU) or chronic spontaneous urticaria (CSU).

The treatment of hives usually begins with oral antihistamines or H1 blockers [e.g., Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine), Xyzal (levocetirizine)]. In some cases, H2 blockers such as Pepcid (famotidine) may be used in combination with the H1 blocker (antihistamine). Leukotriene antagonists [e.g., Singulair (monteleukast)] may also be used if needed. Occasionally corticosteroids may be necessary to treat recalcitrant cases. In addition to the above medications, patients with chronic spontaneous urticaria (i.e., chronic idiopathic urticaria) may benefit greatly with Xolair (omalizumab), a biologic injectable medication which is usually administered monthly.

There are 2 other conditions that are related to hives that should be discussed since they can occur without hives or with hives. They are as follows:

Pruritus: Even though pruritus technically means “to itch,” it should be noted that some individuals just itch without having associated hives while as mentioned above, some itch with associated hives. For the purposes of this blog, pruritus means the former, itching without hives or a rash. The diagnosis and management are essentially the same as with hives except Xolair is not used in patients with just pruritus alone.

Swelling (i.e., angioedema): Similar to pruritus, swelling (i.e., angioedema) may occur simultaneously with hives or the swelling can occur without associated hives. One can think of angioedema as a large hive, so in essence it is not really different from a hive, except it can be scarier to the individual with the swelling. Of course if the swelling is in the throat for example, it can be life-threatening. The diagnosis and treatment are also basically the same as with hives except there is an added blood test (i.e., C1 esterase inhibitor level) that is obtained and like with the treatment of pruritus, Xolair is not used with just angioedema alone.

The board certified allergy doctors at Black & Kletz Allergy located in the Washington, DC, Northern Virginia, and Maryland metropolitan area will readily answer any questions you have regarding hives (i.e., urticarial), itching (i.e., pruritus), swelling (i.e., angioedema) or any other allergic condition. We have 3 offices with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices offer on-site parking. In addition, the Washington, DC and McLean, VA offices are accessible by Metro. There is also a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. Please make an appointment by calling any one of our 3 offices, or alternatively, you can click Request an Appointment and we will answer you within 24 hours by the next business day. Black & Kletz Allergy diagnoses and treats both children and adults and we are proud to serve the Washington, DC metro area residents for which we have done for more than 5 decades.

New Treatments for Eosinophilic Esophagitis

The esophagus is the muscular tube that propels food from the mouth into the stomach through a rhythmic, coordinated peristaltic action. The interior lumen of the tube is covered by a thin mucus membrane. This normal function can be impaired when the structure is chronically inflamed by various allergic triggers. A subset of white blood cells, called eosinophils, accumulate in the mucus membrane of the esophagus in response to the exposure of allergens that an individual is sensitized to. These eosinophils will release a number of chemical mediators of inflammation into the tissues causing structural and functional damage. When this occurs, the individual has a condition called eosinophilic esophagitis (EoE).

Eosinophilic esophagitis is a relatively newly recognized condition. It has been increasingly diagnosed in adults and children over the past couple of decades. The frequency of eosinophilic esophagitis has been estimated to be approximately 1 in 2,000 individuals.

Food allergens are the most common cause of eosinophilic esophagitis. Though any food can be an allergen in theory, the most commonly implicated foods in patients with eosinophilic esophagitis are milk, wheat, soy, eggs, peanuts, tree nuts, and fish/shellfish. Individuals with eosinophilic esophagitis often have other allergic diseases such as allergic rhinitis (i.e., hay fever), asthma and/or eczema (i.e., atopic dermatitis).

Genetic factors play a role in the causation of eosinophilic esophagitis as the condition is known to run in families. Some individuals with this condition have been found to have an unusually high expression of a particular gene named eotaxin-3.


The symptoms of eosinophilic esophagitis ay vary by the age of the patient as well as the severity of the inflammation. The main symptoms are listed below:

  • Difficulty swallowing (i.e., dysphagia)
  • Food getting stuck in the throat (impaction)
  • Nausea/vomiting
  • Abdominal pain
  • Poor appetite/weight loss


The diagnosis is often delayed because of a lack of awareness of this condition. A high index of suspicion is needed for the detection of eosinophilic esophagitis in both children and adults presenting with above symptoms.

In order to confirm the diagnosis of eosinophilic esophagitis, it is necessary to do an upper endoscopy, where a thin flexible tube with a light source is passed into the esophagus through the mouth in order to visualize the esophagus. The appearance of whitish patches (i.e., plaques), furrows, and in late stages, circular rings resulting from scarring, are highly suggestive of eosinophilic esophagitis. Multiple biopsies are needed of the inner esophagus during this procedure. The diagnosis is conclusively established by the demonstration of the excessive accumulation of eosinophils in the biopsy specimens obtained from the esophagus.

Environmental allergies to substances such as pollens, animals, dust mites, and molds possibly play a role in eosinophilic esophagitis. For some patients, it may seem like their eosinophilic esophagitis is worse during pollen seasons. Allergy testing for these common environmental allergens is often part of an eosinophilic esophagitis evaluation.


The treatment of eosinophilic esophagitis involves a variety of approaches:

1. Dietary Modifications:

  • 6 food (i.e., diary, egg, wheat, soy, nuts, seafood) elimination diet
  • Elimination of foods based on allergy skin prick and/or patch testing
  • Elemental (i.e., amino acid) diet

If the symptoms improve while on dietary restriction, foods can be gradually be reintroduced, one food at a time, while closely monitoring for the relapse of symptoms.

2. Drug Therapy:

  • Proton pump inhibitors (e.g., Prilosec, Nexium) improve symptoms in a subset of patients either by reducing the excessive acid production or more likely by a direct anti-inflammatory action over the esophagus.
  • Topical inhaled corticosteroid medications such as fluticasone (i.e., Flovent) and budesonide (i.e., Pulmicort). These are approved only as inhaled anti-inflammatory agents for asthma, but are used off-label as ingestible medications for eosinophilic esophagitis. These medications coat the mucus membrane, reduce the eosinophilic inflammation, and lead to symptom improvement.
  • Additional endoscopies and biopsies are usually necessary to monitor the effectiveness of treatment.

3. Biological Medications:

In 2022, dupilumab (i.e., Dupixent) was approved by the U.S. Food and Drug Administration (FDA) to treat adults and children 12 years and older with eosinophilic esophagitis. This is the first FDA-approved treatment for eosinophilic esophagitis.

Dupixent is administered by injection under the skin once a week. This medication reduces the number of eosinophils in the esophagus and can lead to significant relief from symptoms.


Families often benefit from participating in support groups and organizations. The American Partnership for Eosinophilic Disorders (APFED) and Campaign Urging Research for Eosinophilic Disease (CURED) are two lay organizations that provide valuable reliable resources for individuals with eosinophilic esophagitis.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating eosinophilic esophagitis in both adults and children in patients in the Washington, DC, Northern Virginia, and Maryland metropolitan area for many years. Black & Kletz Allergy has 3 offices in the Washington, DC metro area with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. If you suffer from difficulty swallowing, food getting stuck in your throat, or any other symptom related to eosinophilic esophagitis, please call us to make an appointment at one of our conveniently located offices. Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergists at Black & Kletz Allergy are confident that we will be able to help you get to the bottom of your problem as well as treat this gastrointestinal disorder. We have been serving the Washington, DC metro area for more than 50 years in the field of allergy, asthma, and immunology and we hope to improve your quality of life by reducing or preventing your unwanted and bothersome allergy symptoms.

Pollen Food Allergy Syndrome

Pollen Food Allergy Syndrome (also called pollen food allergy syndrome) is a condition where there is a cross reaction to allergens that are found both in pollen and certain foods. The most common foods associated with pollen food allergy syndrome include fresh fruits, vegetables, and some tree nuts. The disorder affects roughly one-third of individuals with seasonal allergic rhinitis (i.e., hay fever).

The primary inner workings of pollen food allergy syndrome is a genetically determined “sensitization” of the immune system to various pollens and the ensuing “reactions” when exposed to these pollens. The immune system sees these pollens as “foreign” and consequently reacts against them resulting in the irritating symptoms of hay fever. The immune system recognizes the pollen as well as similar proteins in the food and then subsequently directs an allergic response to the allergenic protein. An easy way to think of it is that your body sees the food as the pollen since the allergenic proteins of the food is very similar to the allergenic proteins of the pollen. If you are allergic to a pollen such as birch tree pollen, you will then mount an allergic response to a cross-reacting food such as a raw fresh apple even though you are not allergic to that food (i.e., apple) because your body normally mounts a response to that birch tree pollen. It is important to note that in most instances, the person can eat the food if it is cooked (i.e., baked apple) without allergic symptoms. The reason individuals can usually eat the cooked version of the food is because the heating process changes the structure of the protein of the food so it looks different structurally. This structurally changed food protein is not recognized by the immune system as a protein that is similar to the pollen, and thus no allergic reaction occurs.

The symptoms of pollen food allergy syndrome may include itching of the lips, tongue, gums, palate and/or throat after eating raw fresh fruits, vegetables, and/or some tree nuts (i.e., almond, hazelnut). The symptoms usually start within a few minutes after eating the raw fresh fruits, vegetables, and/or tree nut and generally abates within a few hours. The symptoms of pollen food allergy syndrome are usually minimal, but in rare cases, they can cause throat swelling and/or difficulty in swallowing. Such severe reactions are more likely to occur with peanuts and/or tree nuts. It is important to establish that some people with itchy lips, mouth and/or throat after eating a raw fresh specific fruit, vegetable, and/or tree nut may in fact have a true food allergy to a specific fruit, vegetable and/or tree nut and not have pollen food allergy syndrome. These “real” food-allergic individuals usually will have the same or comparable symptoms even when eating the fruit/vegetable cooked, unlike patients with pollen food allergy syndrome who can usually tolerate the cooked fruit/vegetable without symptoms.

Pollen food allergy syndrome tends to be more prominent and bothersome in the Spring months when one is exposed to higher levels of pollen. Specific tree pollen sensitivity cross-reacts with specific fruit/vegetable/tree nut proteins due to the closeness in the amino acid sequences of the allergenic proteins. For example, patients with birch pollen sensitivity tend to react more commonly with fresh raw pitted fruits (e.g., apples, peaches, pears, apricots, plums) as well as carrots, peanuts, and/or tree nuts. Individuals with allergies to grasses may have a reaction to celery, peaches, melons, (e.g., watermelon, honeydew, cantaloupe), oranges, and tomatoes. Ragweed pollen sensitivity in the Fall usually cross-reacts with bananas, melons, cucumbers, and/or zucchini.

The diagnosis of pollen food allergy syndrome is made commonly by a history of oral pruritus (i.e., itching) and irritation in individuals who have previously tested positive for allergies to pollen and are symptomatic during the corresponding pollen seasons.

The treatment of pollen food allergy syndrome involves evading the offending raw fresh fruits/vegetables/tree nut. Peeling the skin before eating and/or cooking (i.e., baking, microwaving) before eating the food may reduce the severity of the symptoms, as heat denatures the allergenic protein which thus decreases its allergenic potential.

The board certified allergy doctors at Black & Kletz Allergy have expertise in diagnosing and treating pollen food allergy syndrome as well as food allergies. . We are board certified to diagnose and treat both adult and pediatric patients and we have been doing so in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than a half a century. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. For additional convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from food allergies, food sensitivities, or pollen food allergy syndrome we are here to help improve your life by preventing unwanted food-related symptoms that have been so troublesome. Black & Kletz Allergy is devoted to providing the highest quality allergy care in a comfortable, compassionate, and professional environment.

Allergies to Tree Pollen

This year so far it has been much warmer than usual for Winter. Typically in the Washington, DC Northern Virginia, and Maryland metropolitan area, trees begin to pollinate in March. Over the last few years however, tree pollination began in February. This year, we have seen tree pollen in the air in January and February! For many individuals, tree pollen is the cause for terrible hay fever (i.e., allergic rhinitis) symptoms. In addition to hay fever, tree pollen can and does exacerbate asthma symptoms in those who are allergic to trees and also have asthma. Some of the first trees to pollinate in this area include cedar, maple, elm, alder, birch, and poplar.  Later in the Spring season, the principal tree that causes difficulties for people with tree pollen allergies is the oak tree.  Other trees that pollinate during this later time frame include walnut, hickory, and pine.

Interestingly, it is not the flowering trees that generally cause allergy symptoms. Most people think that in the Washington, DC area that the cherry blossoms are a major cause of allergies. In fact, cherry blossoms rarely cause allergies but they tend to bloom when other trees that cause allergies in the area pollinate. People either suffer from tree pollen allergies or see others suffer from tree pollen allergies and associate the blooming of the cherry trees with allergies. It is the “ugly” non-flowering trees that tend to cause allergy symptoms. Why, you may ask? Flowering trees (e.g., dogwood trees, cherry trees, redbud trees, magnolia trees) are pretty for a reason. The pollen from flowering trees is relatively heavy. Since the pollen is heavy, it needs the help of bees to help cross-pollinate. The abdomen of the bees land on the pollen of a flower after being attracted to the flower. The bees then land on another flower and the pollen from their abdomen cross-pollinates the other flowers. Non-flowering trees (e.g., maple trees, oak trees, birch trees, hickory trees), on the other hand, have much lighter pollen which is easily wind dispersed. They cross-pollinate by releasing their pollen into the air and having it blow to other trees. It is the result of this wind dispersal that leads to people becoming allergic to tree pollen. Individuals inhale the tree pollen and they may become sensitized to the pollen which manifests itself by the classic allergy or asthma symptoms.

What are the allergy symptoms for tree pollen allergies? The classic symptoms may include runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, itchy roof of mouth, sneezing, sinus congestion, sinus headaches, itchy eyes, watery eyes, puffy eyes, dark circles under the eyes, and/or redness of the eyes. Other less common symptoms may include fatigue, sore throat, snoring, hoarseness, itchy skin, coughing, and/or feeling like you are in a “fog.” Tree pollen can also trigger asthma or even cause asthma symptoms in those who have never had asthma or asthma symptoms. The classic symptoms of asthma may include chest tightness, wheezing, coughing, and/or shortness of breath.

The diagnosis of tree pollen allergies begins with a comprehensive history and physical examination by a board certified allergist. Allergy testing by skin testing or blood testing is often performed in order to determine if the allergies are caused by tree pollens or other allergens such as molds, grasses, weeds, and/or dust mites. In addition to finding out what the patient is allergic to, the degree of the allergy can be ascertained by the severity of the reaction on skin testing or the degree of positivity on the blood tests.

The management of tree pollen allergies begins with avoidance or prevention, if at all possible. Individuals are encouraged to monitor the pollen counts which can be tracked on the top right of our homepage by clicking Today’s Pollen Count.  In one’s car, it is advisable to keep one’s windows and sunroof closed and to turn on the air conditioner and change the air filters regularly (about once a month).  Use the re-circulate feature in the car so that the air is not coming into the vehicle from the outside.  Choose an automobile that has a filter in its air conditioning unit, if possible.  Stay indoors wherever possible when the pollen count is high (i.e., generally on dry warmer days).  It is important to realize that rain washes away pollen from the air causing pollen counts to be lower on wet cooler days.  Since pollen is released in the early mornings, try to avoid exercising during this time. If a person goes outdoors, shower, wash one’s hair, and change one’s clothing before returning home in order to lessen one’s pollen exposure.  Avoid drying clothes outdoors when the pollen count is elevated.  Avoid yard work and mowing lawns, if possible.  If one needs to do yard work, wear a filtration face mask in order to reduce exposure to the tree pollen.  Avoid contact lenses which may trap pollen in one’s eyes.  Wash one’s pets regularly and avoid close contact with a pet that goes outside during the pollen season since pets carry tree pollen on their coats.

The treatment of tree pollen allergies varies depending on how severe the patient’s symptoms are and if and how the trees affect and alter the desired lifestyle of the individual. Some people do not mind staying indoors in the Spring where others want to participate in outdoor activities such as golfing, jogging, baseball, etc. Oral antihistamines [Clarinex (desloratadine), Allegra (fexofenadine), Zyrtec (cetirizine), Claritin (loratadine), Xyzal (levocetirizine)] and nasal corticosteroids [Flonase (fluticasone), Nasonex (mometasone), Nasacort AQ (triamcinolone), Rhinocort Aqua (budesonide)] are usually the first medications prescribed in individuals that have tree pollen allergies. Oral decongestants [Sudafed (pseudoephedrine)] may be useful in certain patients with nasal congestion assuming there is no contraindication for using them such as hypertension. Other medications may be used and some of these may include oral leukotriene antagonists [i.e., Singulair (monteleukast)], nasal antihistamines [i.e., Patanase (olopatadine), Astelin (azalastine)], nasal anticholinergics [i.e., Atrovent (ipratropium bromide)], and various eye drops. For the treatment of asthma induced by tree pollen, inhaled corticosteroids, leukotriene antagonists, long acting beta 2 agonists, and/or short acting beta 2 agonists are utilized.

The board certified allergists at Black & Kletz Allergy have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area and treat both children and adults with tree pollen allergies. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Black & Kletz Allergy offers on-site parking at each of their 3 office locations and the Washington, DC and McLean, VA offices are also 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 you can click Request an Appointment and we will respond within 24 hours on the next business day. Black & Kletz Allergy has been serving the asthma and allergy needs of the Washington, DC metro area community for more than 5 decades and we strive to offer the highest quality allergy and asthma care in a compassionate and specialized environment.

Respiratory Syncytial Virus (RSV)

Nearly all children get infected with respiratory syncytial virus (RSV), a highly contagious virus, by their second birthday. RSV has a seasonal predilection, usually from December to March every year. In most instances, it causes mild “cold-like” symptoms and resolves without complications in approximately 1-2 weeks.

Although most cases get better and resolve on their own, respiratory syncytial virus can sometimes lead to severe illness requiring visits to the emergency room. In some cases, hospitalization may be required. The incidence of severe illness due to RSV is especially high during the Winters in the U.S. Surging RSV infections in conjunction with the rise in flu and COVID-19 infections has been termed the “tripledemic.”

RSV is especially severe in very young children and adults over 65 years of age. Predisposing factors to severe RSV infections may also include underlying chronic lung and/or heart conditions as well as having a compromised immune system.

Respiratory syncytial virus is the most common cause of bronchiolitis (i.e., inflammation of the small airways in the lungs) in children younger than 1 year of age. RSV causes approximately 60,000 hospitalizations among children under the age of 5 annually. RSV infection is estimated to cause approximately 15,000 annual deaths in the U.S. in adults over the age of 65. Respiratory syncytial virus is the leading cause of lower respiratory tract infection in children and is a common cause of wheezing in infants and young children. Studies suggest that a severe RSV infection early in childhood is linked to development of asthma later in life.

The infection of respiratory syncytial virus spreads from person to person primarily by contact with respiratory secretions and to a lesser extent by aerosol and droplets. RSV can survive for many hours on hard surfaces such as tables and door handles and lives on soft surfaces such as tissues and hands for shorter amounts of time.

The symptoms of respiratory syncytial virus usually begin 2 to 3 days after contact with the virus. The initial symptoms usually include nasal congestion and runny nose with clear mucus secretions, an itchy throat and a dry cough. Children can also experience mild fevers, poor appetite, and reduced physical activity.

For babies, thick mucus can clog up the nose and small air passages in the lungs, making it difficult for them to breathe. Narrowed bronchial tubes may also cause wheezing in addition to a severe cough. Respiratory distress requires hospitalization where supplemental oxygen and inhaled medications can be administered.

Older adults, especially those with asthma, chronic obstructive pulmonary disease (COPD), heart diseases, and/or diabetes mellitus can develop pneumonia from an RSV infection. The virus can also aggravate their underlying lung conditions requiring emergency treatment.

The diagnosis of RSV is suspected by clinical presentation and can be confirmed by laboratory tests using a nasal mucus swab. Imaging of the lungs may also be needed in order to evaluate the severity of the condition.

The treatment of respiratory syncytial virus is only supportive care in most instances as there is no specific medication available. For young children, nasal saline with gentle suctioning and a cool-mist humidifier may help with their breathing.

In severe cases, intravenous (IV) fluids may need to be given in order to treat dehydration. Oxygen supplementation may be needed to relieve any breathing difficulty.

A medication known as Synagis (palivizumab) is sometimes prescribed in order to minimize or prevent serious RSV disease among high-risk infants and children less than 2 years of age. This drug does not improve symptoms for children already suffering from RSV, nor does it prevent infection with RSV.

People infected with RSV are usually contagious for 3 to 8 days and may become contagious 1 to 2 days before they begin showing signs of the illness.

One of the most effective ways to prevent an RSV infection is to practice good hand hygiene. Frequent hand washing, covering sneezes and coughs, and avoiding direct contact with unclean surfaces are very helpful in minimizing the spread of respiratory syncytial virus.

Effective vaccines and therapeutics to prevent and treat RSV infections are in active development. The research into developing an RSV vaccine began in the 1960’s and this year (2023) RSV vaccines should be on the market. The pharmaceutical companies Pfizer, GSK, and Moderna have been working on such a vaccine and are all close to the final product. Pfizer and GSK announced promising Phase III results in 2022 and they are now both awaiting regulatory approval for the vaccine.

The board certified allergists at Black & Kletz Allergy see both adult and pediatric patients and have over 5 decades of experience in the field of allergy, asthma, and immunology. Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day. We have been servicing the greater Washington, DC metropolitan area for over 50 years and we look forward to providing you with the highest state-of-the-art allergy care in a friendly and relaxed environment.