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Oral Allergy Syndrome

Oral allergy syndrome (also known as pollen food allergy syndrome) affects approximately one third of people with seasonal allergic rhinitis (i.e., hay fever).

The symptoms of seasonal allergic rhinitis may include nasal congestion, runny nose, itchy nose, sneezing, itchy eyes, watery eyes, and/or red eyes during tree, grass and/or weed pollinating seasons. In our geographical area, the trees and grasses pollinate mostly in Spring and early Summer and the weeds, especially ragweed, pollinate in the Fall. It is common for these individuals to experience the symptoms during those seasons. The underlying mechanism of oral allergy syndrome is a genetically determined “sensitization” of the immune system to various pollens and subsequent “reactions” when exposed to these pollens. The immune system considers these pollens as “foreign” and thus reacts against them resulting in the annoying symptoms of hay fever.

A number of individuals with pollen allergies will experience a situation where they will develop itching of the lips, gums, tongue, palate and/or throat after eating raw fresh fruits and/or vegetables. This condition is termed pollen food allergy syndrome or oral allergy syndrome. This occurs because of the similarity of the protein antigens in the pollen and the protein antigens of the fresh fruits and/or vegetables. The immune system which is previously sensitized to pollen will also react to the similarly structured proteins in the fruits and/or vegetables. This phenomenon is termed cross-reactivity. Thus when an individual who has a pollen allergy eats certain raw fresh fruits and/or vegetables, the person’s immune system “thinks” that they are being exposed to pollen proteins when in fact they are being exposed to fruit/vegetable proteins that have a very similar structure to the pollen proteins. The body in turn reacts to the fruit/vegetable proteins in a similar fashion as a typical allergic reaction but is usually more localized to where the food makes direct contact, such as the lips, gums, tongue, palate, and/or throat.

This condition tends to be more prominent and bothersome in the Spring months when we are exposed to higher levels of pollen. Specific tree pollen sensitivity cross-reacts with specific fruit/vegetable proteins due to the closeness in the amino acid sequences. For example, patients with birch pollen sensitivity tend to react more commonly with fresh raw pitted fruits (e.g., peaches, apricots, plums), apples, and/or carrots. Birch pollen allergy can also cross-react with peanuts and/or tree nuts.

Individuals with allergies to grasses may have a reaction to peaches, celery, tomatoes, melons (e.g., cantaloupe, watermelon, honeydew), and oranges. Ragweed pollen sensitivity in the Fall usually cross-reacts with melons, bananas, zucchini, and/or cucumbers.

The symptoms usually begin within a few minutes after eating the raw fresh fruits and/or vegetables and generally subside within a few hours. The symptoms of oral allergy syndrome typically include itching of the lips, mouth, and/or throat as mentioned above. The symptoms are usually mild, but in rare cases, can cause throat swelling and/or difficulty in swallowing. Such severe reactions are more likely to happen with peanuts and/or tree nuts. It is important to note that some people with itchy lips, mouth and/or throat after eating a raw fresh specific fruit and/or vegetable may in fact have a true food allergy to a specific fruit and/or vegetable and not have oral allergy syndrome. These truly food-allergic individuals generally will have the same or similar symptoms even when eating the fruit/vegetable cooked, unlike patients with oral allergy syndrome who can generally tolerate the cooked fruit/vegetable without symptoms.

The diagnosis is established mostly by a history of oral pruritus (i.e., itching) and irritation in patients who have previously tested positive to pollen and are symptomatic during the respective pollen seasons.

The treatment of oral allergy syndrome involves avoiding the offending raw fresh fruits/vegetables. Peeling the skin before eating and/or cooking (i.e., baking, microwaving) before eating may decrease the severity of the symptoms, as heat denatures the protein and reduces its allergenic potential.

Below is a chart from the American Academy of Allergy, Asthma & Immunology of different types of pollens and the corresponding foods that may cause oral allergy syndrome:

SPRING               SUMMER                LATE SUMMER – FALL               FALL

Pitted Fruit
Apple                         X
Apricot                      X
Cherry                       X
Peach                         X                               X
Pear                            X
Plum                          X

Cantaloupe                                                                                                 X
Honeydew                                                                                                   X
Watermelon                                                X                                             X

Banana                                                                                                         X
Kiwi                            X
Orange                                                         X
Tomato                                                        X

Bell pepper                                                                                                                                           X
Broccoli                                                                                                                                                 X
Cabbage                                                                                                                                                X
Carrot                         X
Cauliflower                                                                                                                                           X
Celery                          X
Chard                                                                                                                                                     X
Cucumber                                                                                                    X
Garlic                                                                                                                                                     X
Onion                                                                                                                                                     X
Parsley                        X                                                                                                                        X
White potato                                                X                                           X
Zucchini                                                                                                      X

Aniseed                                                                                                                                                  X
Caraway                                                                                                                                                 X
Coriander                                                                                                                                              X
Fennel                                                                                                                                                    X
Black pepper                                                                                                                                         X

Peanut                       X
Soybean                    X

Almond                     X
Hazelnut                   X

*Mouth or throat itching from peanut, soybean, almonds, and hazelnuts may also be an initial
manifestation of a more serious food allergy with the potential for anaphylaxis. See an
allergist/immunologist if such symptoms are noted.

© 2019 American Academy of Allergy, Asthma & Immunology.


The board certified allergists at Black & Kletz Allergy have been diagnosing and treating oral allergy syndrome and food allergies for more than 50 years. We treat both pediatric and adult patients. 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 further 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. To schedule 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 an itchy mouth or throat after eating fruits and/or vegetables or you have other food allergy symptoms, we are here to help diagnose and treat your food allergy. The allergists at Black & Kletz Allergy are happy to help you with any allergic condition that you may have as we are dedicated to providing you with the highest quality allergy care in a relaxed, caring, and professional environment.

Bug Bite and Sting Allergies and Reactions

Bug bites are certainly very common. Almost everyone has been bitten by a bug in their lifetime and almost everyone has had at least a minor local reaction to the bug bite. In some instances, an individual may have a more severe reaction that is not an allergic reaction but it can mimic an allergic reaction. In other cases, however, an individual may actually have a true allergic reaction. In order to differentiate between an allergic reaction and a non-allergic reaction, a consultation with a board certified allergist may be necessary.

There are 4 basic types of reactions that may occur from a bug bite. They are classified as follows:

  • Local irritant reaction
  • Allergic reaction
  • Toxic reaction
  • Serum sickness reaction

The first two reactions are by far the most common. Overwhelmingly, a local irritant reaction is the most common of the four reactions. The symptoms of a local irritant reaction may include local redness, pain, itching, and/or swelling. It is generally self-limited and usually resolves on its own without treatment. If treatment is desired, one can use over-the-counter (OTC) antihistamines or OTC topical corticosteroids to treat this type of reaction.

An allergic reaction to a bug bite is not very common, however they do occur. Symptoms can mimic a local irritant reaction but the reaction may be more severe. Additional symptoms may include blistering of the skin, generalized itching of the skin, throat closing sensation, hives (i.e., urticaria), warm feeling, increased heart rate, drop in blood pressure, lightheadedness, dizziness, fainting, wheezing, and/or shortness of breath. It is more common to have true allergic reactions to the venom of stinging insects such as honey bees, yellow jackets, hornets, wasps, and fire ants. The treatment of an allergic reaction to a bug bite is aimed at treating and controlling the symptoms. OTC antihistamines and/or OTC topical corticosteroids are generally adequate enough in to treat this condition. Occasionally, prescription medications such as more potent antihistamines, histamine2-blockers (e.g., Pepcid, Tagamet), leukotriene antagonists (e.g., Singulair), and/or oral corticosteroids may be necessary in order to treat the allergic reaction. Rarely, the use of asthma inhalers (e.g., albuterol) may be necessary in individuals who develop symptoms of asthma which may include shortness of breath, chest tightness, coughing, and/or wheezing. An individual who has had a systemic allergic reaction to a stinging insect (e.g., honey bees, yellow jackets, hornets, wasps, fire ants) should be skin tested by a board certified allergist. If that individual reacts to the venom skin testing, it is strongly recommended that this person go on a course of venom immunotherapy (i.e., allergy shots for stinging insects) as they are very efficacious in preventing anaphylaxis. It is very important that such an individual carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) in case they are stung, as insect sting allergies can be fatal. If the epinephrine device is used, it is imperative that the patient go immediately to the closest emergency room. It also should be known that honey bees leave their stingers in their victims and if stung by a honey bee, never pull out the stinger. Instead, one should scrape off the stinger. Pulling out a stinger may cause the pinching of the venom sac, which may in turn cause the venom sac to introduce more venom into the affected person.

A toxic reaction to bug bites or stings occurs when a bug introduces various substances into an individual such as a toxin or venom. Assuming there is not an allergic reaction to the venom, as mentioned above, the venom may act as a poison and cause direct harm to the tissues of the individual. Toxic reactions can occur from one sting or bite from a highly toxic insect or spider, or from multiple stings or bites from insects or spiders not normally considered poisonous. The symptoms of a toxic reaction may include nausea, vomiting, fever, fainting, lightheadedness, pain or redness or swelling at the site of the sting or bite, headache, muscle spasms, seizures, and/or shock. It is even potentially fatal. The treatment of a toxic reaction to bug bites or stings is primarily based on supportive care. Antihistamines and corticosteroids may be used. In addition, standard wound care precautions and treatment should be utilized as it is not uncommon for the site of the bite or sting to become infected. Antibiotics should be used when needed.

The fourth type of reaction that can occur due to a bug bite or sting is serum sickness. Serum sickness can occur as a result of a reaction towards the venom of either insect stings or spider bites. The symptoms generally manifest hours to days after the sting or bite. The classic symptoms may include fever, joint pain, itching, rash or hives, and/or fatigue. Other symptoms may include swollen lymph nodes, enlarged spleen, drop in blood pressure, and/or shock. In addition to venom, medications (e.g., penicillins, cephalosporins, allopurinol), blood products (e.g., transfusions), and antitoxins (e.g., antivenom) have been known to rarely cause serum sickness. The treatment of serum sickness usually entails antihistamines, corticosteroid creams, and/or nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen). In severe cases, oral corticosteroids are often utilized.

If you or someone you know have experienced an insect sting or bug bite and had more than a minor reaction, the board certified allergists at Black & Kletz Allergy are here to help. We diagnose and treat both adults and children in all facets of allergy, asthma, and immunology. We often see patients for consultations about insect stings and bug bites. Our allergists will perform venom testing on those individuals who meet the requirement for testing. In addition, a specific plan for future stings and/or bites will be discussed with the patient in order to reduce the individual’s fear and confusion regarding reactions to the bite and/or sting. 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 further 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. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment as we have done for over 50 years.

Penicillin Allergy

Penicillin allergy is reported in roughly 7-10% of the general population and in up to 20% of hospitalized patients. Even though the reported numbers are fairly high, approximately 90% of these reported cases do not actually have a penicillin allergy. Individuals think they are allergic, but in most cases, the symptoms that they experience are either a non-allergic side effect or completely unrelated to penicillin. An allergy to penicillin, however, appears to be the most common medication allergy, along with other antibiotics.

Penicillin is comparatively inexpensive while being very efficacious. This make it both a common as well as a good choice for clinicians to use when an antibiotic is necessary. For those who have a true allergy to penicillin, the penicillin is seen as a foreign “invader” and one’s immune system mounts a defensive response in order to try to subdue the “invader.” When the immune system mounts a response, chemical mediators are released into the bloodstream in order to attack the intruder. As a result of these chemical mediators (e.g., histamine, leukotrienes), the individual may experience itching, hives, and/or swelling. In severe cases, an anaphylactic reaction may occur where individuals may develop wheezing, shortness of breath, rapid heartbeat, and/or drop in blood pressure.

Most people with a probable history of penicillin allergy are given alternative antibiotics in order to treat infections.  In most cases, the replacement antibiotic will be more expensive than penicillin. It also may not be as effective as penicillin. In addition, the use of a replacement antibiotic can result in bacteria developing resistance to these alternative antibiotics, which will be a detriment to the community as a whole.  In the field of allergy and immunology, is important to distinguish between a “false” allergy and a “true” allergy to penicillin and related antibiotics, so that the correct and appropriate antibiotic can be utilized. The evaluation of penicillin allergy requires the use of a standardized penicillin testing protocol. At Black & Kletz Allergy, our board certified allergists routinely perform this procedure in our office. Skin testing has been used for the diagnosis and management of penicillin allergy since the 1960’s.  The procedure is commonly performed with minimal risk.  Penicillin skin testing can be done safely in properly selected patients with suspected penicillin allergy.

The procedure for penicillin skin testing involves 3 steps:

  • Skin prick testing with a small amount of diluted penicillin allergens, negative control solution, and positive control solution.
  • If the prick tests are negative after 20 minutes, intradermal skin testing is performed where a very small quantity of the allergen, negative control solution, and positive control solution is injected into the superficial layers of the skin.
  • If the intradermal skin test in in this second stage is also negative after 20 minutes, the patient will be given 250 mg. of amoxicillin by mouth (i.e., oral challenge) and will be closely monitored for 90 minutes.

If the patient tolerates all 3 stages without any untoward effects, the patient may receive penicillin if needed without an increased risk of an immediate allergic reaction than that of the general population. Penicillin testing should only be performed in a healthcare setting only by an allergist with the knowledge, training, and experience to select appropriate patients for this procedure, interpret the test results, and manage a systemic allergic reaction if it were to occur. This procedure can accurately identify the roughly 9 of 10 patients, who despite reporting a history of penicillin allergy, can receive penicillin safely. It should be noted that most individuals who say that they are allergic to penicillin because “they were told they had a reaction as a young child” turn out not to have a penicillin allergy when tested by a board certified allergist. It is however important to be tested and to not just assume you will be negative. All presumed “penicillin-allergic” individuals should continue to avoid penicillin until they are tested by an allergist.

The board certified allergists at Black & Kletz Allergy have been diagnosing and managing penicillin allergy, as well as other medication allergies for more than 50 years. We treat both pediatric and adult patients. 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 further 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, yo

hand with pen drawing the chemical formula of Penecillin

u can click Request an Appointment and we will respond within 24 hours by the next business day. If you have a penicillin allergy or think you have a penicillin allergy, we are here to help you by testing you to see if you are allergic to penicillin. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

Reactions to Food Additives

The food we consume everyday contains many natural and artificial additives. Most of these additives to food are chemicals and biological substances. In most of the cases, they are usually either preservatives or coloring substances.

Though additives have been used for hundreds of years, there has been an increase in the number and variety of substances added to food in the past few decades. The Food and Drug Administration (FDA) lists more than 4,000 different additives on their Food Additive and Color Additive lists.

Some of us can be “intolerant” to food additives, however, food additives may cause both immediate (i.e., symptoms beginning within a few minutes of eating food) and/or delayed (i.e., symptoms beginning several hours after eating food) hypersensitivity reactions. Immediate reactions are mediated by an antibody called IgE and delayed reactions are usually caused by T-lymphocytes (i.e., T-cells). The exact mechanism of reactivity however, may be unknown in a number of reactions caused by the additives.

Two common additives found in food in the U.S. that need special mention include sulfites and food dyes.


Sulfites are one of the most commonly used preservatives for foods. They reduce spoilage and prevent fruit and vegetable browning. They also have some beneficial anti-oxidant properties. Sulfites are present in dried fruits in high quantities. They are also usually added to baked goods, shrimp, and condiments. Sulfites are also present in several varieties of wines and beers.

There are many case reports of sulfites causing hives (i.e., urticaria), angioedema (i.e., soft tissue swellings), and flare-ups of asthma. The FDA now requires that most preservatives, including sulfites, be cleared mentioned in the food labels. Sulfites can appear as alternate verbiage on product labels and can be written as potassium bisulfite, potassium metabisulfite, sodium bisulfite, sodium metabisulfite, or sodium sulfite.

Sulfite, sulfa, sulfate, and sulfur are 4 terms that sound very similar but are very different when it comes down to their allergy profile. Sulfa drugs contain the sulfonamide molecule and are typically broken down to sulfonamide antimicrobials (i.e., antibiotics) and sulfonamide non-microbials. The chemical structures are different between the sulfonamide antimicrobials and the sulfonamide non-microbials and thus individuals who have allergic reactions to one group should not have allergic reactions to the other group of sulfonamides. It should be noted that approximately 3% of individuals are allergic or have adverse effects from sulfonamide antimicrobials. The sulfonamide antibiotics may include sulfamethoxazole (i.e., Bactrim, Septra), sulfafurazole, sulfisoxazole (i.e., Pediazole), and sulfadiazine. The non-microbial sulfonamides may include Celebrex (i.e., celecoxib), Lasix (i.e., furosemide), Microzide (i.e., hydrochlorothiazide), Imitrex (i.e., sumatriptan), Amaryl (i.e., glimepiride), and Diabeta (i.e., Glyburide).

Sulfates are present in many medications (i.e., magnesium sulfate, ferrous sulfate), supplements (i.e., glucosamine sulfate), and personal care products (toothpaste, shaving foam, shampoo). Sulfates are different chemically from sulfites and sulfa drugs and are unlikely to cause allergic reactions.

Sulfur is a chemical element and omnipresent. It is thus practically impossible to have an allergy to sulfur.

Food Dyes:

Carmine is a coloring agent present in red-colored foods. It is extracted from the insect known as the cochineal. It is known as “cochineal extract” or “natural red 4.” It has been shown to cause facial swelling, rashes, wheezing, and/or anaphylaxis.

Saffron, annatto, and yellow dye # 5 are added to foods to color them yellow. Saffron is a spice that has been around for thousands of years. It can be toxic in larger quantities. An allergy to saffron is known to cause itching, skin irritation, rashes, redness of the skin, and hives. Annato comes from the seeds of the achiote tree and can be found in some cereals, drinks, cheeses, and snack foods. It has been shown to cause rashes and anaphylaxis is some individuals. Yellow dye # 5 (i.e., tartrazine) is known to cause hives and angioedema is selected individuals. It is also known to trigger asthma in some individuals.

It is important to note that any food dye may cause allergic reactions in susceptible individuals. Although food dye allergies are not too common, it is important to be aware that reactions such as itchy skin, redness of the skin, hives, angioedema, and anaphylaxis may occur.


If one experiences untoward reactions to many different unrelated foods or if reactions occur only after eating commercially packaged foods, sensitivity to the additives should be suspected. Maintaining a food and symptom diary can be helpful in narrowing down the additive in question by establishing a temporal relationship between exposure and the onset of adverse effects.

Skin prick testing or blood testing are not useful in the diagnosis of food additive sensitivity; however, they may be useful in ruling out specific foods. Oral food challenges are usually helpful in the diagnosis. In this procedure, foods are eaten in small increments at regular intervals, beginning with a tiny quantity, while closely monitoring for adverse reactions under controlled circumstances with standardized protocols to treat an allergic reaction.


Avoidance of the foods containing the suspected or confirmed sensitizing additive is essential in order to prevent untoward reactions. Careful reading of labels before eating is essential in reducing the likelihood of reactions. Enquiring about the specific ingredients of a dish in restaurants will go a long way in preventing untoward symptoms.

Patients with a history of anaphylaxis triggered by either known or unknown substances should always carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) at all times. If the device is used, the patient must go immediately to the closest emergency room.

The board certified allergy doctors at Black & Kletz Allergy have 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Our 3 office locations have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible. Our McLean office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line. The allergy doctors at Black & Kletz Allergy diagnose and treat both adult and pediatric patients. To schedule an appointment, please call our office directly or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. The allergy doctors at Black & Kletz Allergy have been serving patients with food additive allergies, food allergies, hay fever (i.e., allergic rhinitis), asthma, sinus disease, hives, eczema, insect sting allergies, medication allergies, and immunological disorders for more than 50 years. If you are bothered from allergies, it is our mission to improve your quality of life by reducing or preventing your unwanted and bothersome allergy symptoms.

Cold Allergies

As we enter into the Winter months, a sensitivity to cold temperatures may trigger some allergic reactions in susceptible individuals. Below are some conditions where exposure to cold can cause clinical disease.

Cold-Induced Urticaria:

Exposure of the skin to cold temperatures can be a trigger for breaking out in hives. Cold-induced hives (i.e., urticaria) typically manifest themselves as intensely itchy, red raised blotches (i.e., welts) of various shapes and sizes over the exposed skin. The hives usually begin to develop within 5 to 10 minutes after the exposure to cold, usually when the skin is rewarming. This condition (i.e., cold-induced urticaria) is usually noticed after returning indoors from cold temperatures outdoors or after swimming and coming out of a cold water pool. The hives generally last for about 1 to 2 hours.

More severe cases of cold sensitivity may also result in anaphylaxis, a life-threatening condition in which in addition to hives one may also experience systemic symptoms such as nausea, dizziness, difficulty in breathing, and/or fainting. This condition is referred to as cold-induced anaphylaxis. Certain viral infections are thought to play a role in the etiology of this disorder.

The diagnosis of cold-induced urticaria or cold-induced anaphylaxis entails comprehensive history taking, a physical examination, and an “ice cube test.” This involves placing an ice cube in a plastic bag over the skin and keeping it in place for approximately 10 minutes before removing it. As the skin rewarms, an itchy, red, welt appears on the skin in the shape of the ice cube with slightly raised edges. A positive ice cube test confirms the diagnosis of cold-induced urticaria.

Treatment of this condition involves avoidance of the exposure to cold temperatures at all times. Bundling up before venturing out into cold weather and checking the temperature of water before swimming are helpful in preventing acute episodes. Avoidance of drinking cold beverages may also be helpful in certain patients.

When avoidance to the exposure of cold is not possible or practical, taking antihistamines can minimize the severity of symptoms. Periactin (i.e., cyproheptadine) is a first generation antihistamine that has been proven to be beneficial in this condition.

A recent study in 2019 found that a “biologic” medication named Xolair (i.e., omalizumab) was also effective in preventing cold-induced hives when taken as a subcutaneous injection every 4 weeks.

Individuals with a history of cold-induced anaphylaxis should be trained in the proper technique of using an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) and carry it at all times. It is available at most pharmacies in various brand names and requires a prescription from a physician. It should be noted that an individual should go to the nearest emergency room immediately if the self-injectable epinephrine device was used.

Many patients with cold-induced urticaria notice that their symptoms usually become less frequent and less severe after 5 to 10 years.

Familial Cold Autoinflammatory Syndrome:

Familial cold autoinflammatory syndrome (FCAS), also known as familial cold urticaria, is a rare, inherited inflammatory disorder characterized by occasional episodes of rash, fever, joint pain, and/or other signs or symptoms of systemic inflammation triggered by the exposure to cold. The onset of FCAS occurs during infancy and early childhood and persists throughout the patient’s life.

Other symptoms may include profuse sweating, drowsiness, headache, extreme thirst, red eyes, blurred vision, eye pain, watering eyes, nausea and/or vomiting.

Symptoms typically occur within hours after exposure to cold. In most cases, a rash will occur within the first 1-2 hours, followed by a fever and joint pain. Episodes usually last for less than 24 hours.

The treatment of familial cold autoinflammatory syndrome may include non-steroidal anti-inflammatory drugs (NSAIDs) which are often used to alleviate joint pain. High doses of corticosteroids have shown to be somewhat effective, but may cause short and long-term side effects.


Chilblains is a vascular condition in which the very small blood vessels become inflamed when exposed to cold air. Symptoms may include red skin, itching, pain, blistering, and/or swelling. These symptoms usually resolve within a few weeks, especially if the weather gets warmer.

Raynaud’s Disease/Phenomenon:

Raynaud’s disease primarily affects the fingers and toes. It usually occurs when an individual is exposed to the cold. Individuals with this condition have blood vessel constriction that causes an interruption in the flow of blood to their extremities.

Symptoms may include pain and paleness or blueness of the skin in the affected areas following exposure to cold temperatures. Symptoms may last minutes or hours. This disorder may be associated with other underlying conditions such as connective tissue disorders (e.g., rheumatoid arthritis, systemic lupus erythematosus), smoking, certain medications (e.g., high blood pressure medications, ADHD medications, hormones), certain foods (e.g., caffeine), and carpal tunnel syndrome. If no associated underlying condition is found, it is referred to as Raynaud’s phenomenon.

Cold Agglutinin Disease:

In individuals with cold agglutinin disease, the body attacks its red blood cells in response to their blood temperature falling to a lower temperature than their regular body temperature.

This condition can result in hemolytic anemia (i.e., a disorder where one’s red blood cells are destroyed faster than they are made). It’s often associated with mycoplasma pneumonia infection, scarlet fever, staphylococcal infections, and rheumatological conditions.

Paroxysmal Cold Hemoglobinuria:

Paroxysmal cold hemoglobinuria is a rare autoimmune disorder usually seen in children in response to cold exposure after an infection. It mainly affects the hands and feet. The symptoms may include dark brown colored urine (due to blood pigment), fever, anemia, abdominal pain, and difficulty in breathing. The condition has been linked to secondary syphilis, tertiary syphilis, and other viral or bacterial infections.

The board certified allergists at Black & Kletz Allergy located in the Washington, DC, Northern Virginia, and Maryland metropolitan area will readily answer any questions you have regarding your hives (i.e., urticarial), allergies, and/or asthma.  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.  We also have a free shuttle that runs between our 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, which we have done for more than 5 decades.

Allergies in the Winter

As Winter approaches, many individuals may begin to complain of allergy symptoms that are similar, if not identical to, the classic hay fever (i.e., allergic rhinitis) symptoms that most people associate with the Spring and/or Fall seasons. These symptoms may include runny nose, nasal congestion, post-nasal drop, sneezing, itchy throat, itchy eyes, watery eyes, redness of the eyes, snoring, sinus congestion, and/or sinus headaches. In certain susceptible patients with asthma, exacerbations may also occur and these individuals may also experience chest tightness, wheezing, coughing, and/or shortness of breath. In addition, the cold air that occurs during the Winter as well as upper respiratory infections (URI’s) that are more common during the Winter may also be triggers for worsening of one’s asthma.

The most common and likely allergens to affect allergic individuals during the Winter are dust mites, molds, pets, and cockroaches. It should be noted that these allergens are perennial allergens as they can bother an allergic individual throughout the year.

Dust mites are the major component of dust and these mites are highly allergenic to certain individuals. They tend to live in bedding (i.e., pillows, mattresses, box springs), upholstered furniture, plush toys, and carpeting. It is important for dust-allergic patients to reduce their exposure to dust. This can be accomplished by covering their pillows, mattresses, and box springs with allergy proof encasings. These encasings help prevent someone from breathing in the dust mites thereby minimizing dust exposure.

Molds are ubiquitous and particularly bothersome and numerous in the Washington, DC, Northern Virginia, and Maryland metropolitan area. Contrary to popular belief, molds may exist in both humid and dry environments. Washington, DC was built on a swamp, so mold growth is inherent in this area. Molds tend to be more prevalent in kitchens, bathrooms, and basements. Molds often are difficult to eradicate. Although the exact numbers are debatable, it is generally recommended that the humidity in the home be set to less than 50% and the temperature should be set below 78°F in order to help prevent mold growth.

Pets are a common source of allergies in a home. Cats, dogs, and birds are the primary culprits for most families. The pet should be limited to certain areas of the home and it is generally recommended that the pet stay out of the bedroom of the affected allergic individual. In addition to being allergic to the pet itself by way of its dander and/or urine, a pet can bring in outdoor allergens via their coat after being outdoors. It is not uncommon for a dog or cat to transfer pollens on their fur from the outside to the inside of one’s house. A common misconception is that some dogs are hypoallergenic. Although not technically correct, there does appear to be less allergy symptoms for some individuals who have certain breeds of dogs that typically do not shed their coats (i.e., poodle, Portuguese Water Dog, Maltese).

The mere mention of cockroaches can get anyone up in arms, however, exposure to cockroaches is quite common, particularly in those living in the inner cities. In fact, it is fairly common trigger in inner city children with asthma. Cockroaches survive in almost any condition and are far more numerous that they might appear. There are more than 4,600 species of cockroaches around the world, although only about 30 species are associated with human habitats. It is said that for every cockroach seen in the home, there are many more hiding. If you have cockroaches, it is advisable to contact a pest-control company in order to eradicate the cockroaches from your home.

In addition to allergic rhinitis and asthma that can be adversely affected in the Winter by the factors mentioned above, the cold temperatures of the Winter may also cause or aggravate certain skin conditions. Hives (i.e., urticaria), generalized itching (i.e., pruritus), and swelling episodes (angioedema) are skin conditions that are diagnosed and treated by board certified allergists, like the ones at Black & Kletz Allergy. The conditions are called cold-induced urticaria, cold-induced pruritus, and cold-induced angioedema respectively. In these maladies, the exposure to the cold can cause hives, generalized itching or swelling. Rarely, the cold can cause a more severe reaction known as anaphylaxis which is very serious and potentially fatal. This condition is called cold-induced anaphylaxis. Individuals with this condition should carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) which is to be used if anaphylactic symptoms occur. One should always go to the closest emergency room after using a self-injectable epinephrine device as the device may only work for about 15-20 minutes.

If you suffer from allergic rhinitis, asthma, hives, generalized itching, swelling episodes, anaphylaxis, or cold-induced symptoms of any kind, the board certified allergy doctors at Black & Kletz Allergy have the expertise in order to diagnose and treat your condition. We treat both pediatric and adult patients and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible. Please either call us for an appointment or you may alternatively click Request an Appointment and we will respond within 24 hours by the next business day. The allergy specialists at Black & Kletz Allergy have been treating allergy and asthma patients in the Washington, DC metro area for more than 50 years and we strive to provide state-of-the-art allergy care to the community.

Vocal Cord Dysfunction

The vocal cords are V-shaped tissue folds within our voice box (i.e., larynx). The gap between the arms of the V is the opening into our windpipe (i.e., trachea). These are dynamic structures and move with the contraction and relaxation of the muscles attached to them. Normally the vocal cords open when we inhale and exhale, allowing the air to get in and out of lungs. They close while we eat, blocking food from entering into the windpipe. The vocal cords become narrowed when we speak. It is the vibration of the vocal cords that generates voice.

When the vocal cords malfunction, they may become narrowed or even close when we inhale. This narrowing or closing will result in difficulty for air to enter the lungs which may cause a feeling of breathlessness. This shortness of breath may be confused with the symptoms of asthma. When this situation occurs, it is referred to as paradoxical vocal fold movement (PVFM) or vocal cord dysfunction (VCD).

In asthma, the airways (i.e., bronchial tubes) constrict and tighten, making breathing difficult. In vocal cord dysfunction, the vocal cord muscles tighten, which also makes breathing difficult. Unlike asthma, vocal cord dysfunction is not an allergic response. It is usually more difficult to inhale during an episode of vocal cord dysfunction. On the contrary, it is usually more difficult to exhale during an exacerbation of asthma. It is very important to differentiate vocal cord dysfunction from asthma since the treatments are quite different. One study showed that approximately 40% of individuals with vocal cord dysfunction are misdiagnosed as having asthma. It should be noted that in some instances, asthma and vocal cord dysfunction can coexist in a person at the same time.

Vocal cord dysfunction is found in people of all ages, although it tends to be more prevalent in individuals between the ages of 20-40. It is more common in women.


  • Tightness of the throat
  • Hoarseness
  • Choking or suffocation feeling
  • Difficulty in breathing
  • High pitched noise during Inhalation (i.e., stridor)
  • Coughing
  • Wheezing
  • Frequent throat clearing

Causes and Triggers:

  • Strong odors, fumes, or other irritants
  • Upper respiratory infections (URI’s)
  • Post-nasal drip associated with allergic rhinitis (i.e., hay fever) or a URI
  • Acid reflux [i.e., gastroesophageal reflux disease (GERD)]
  • Exercise
  • Emotional stress


  • Comprehensive history of the symptoms and triggers
  • Breathing test (i.e., spirometry) with a flow/volume loop demonstrating diminished air entry into the lungs during an episode
  • Direct inspection of the of the vocal cord through a laryngoscope (i.e., flexible fiberoptic tube with a camera attached) during the episode revealing paradoxical movements
  • An episode may need to be “induced” either by exercise or by inhalation of a chemical called methacholine


There is very little role of medications in the management of this vocal cord dysfunction. The mainstay of treatment is behavioral techniques to relax the muscles in the throat that control the vocal cord movements.

  • Speech therapy by a trained and qualified speech pathologist and therapist is the main course of treatment. One may need several sessions of speech therapy and regular practice at home even during asymptomatic periods in order to manage vocal cord dysfunction.
  • Deep breathing techniques to reduce the discomfort and fear
  • Relaxation techniques, biofeedback, and psychotherapy have been shown to be helpful in controlling vocal cord dysfunction by reducing emotional stress
  • Better control of asthma, if it is co-existent
  • Managing post-nasal drip and acid reflux

The board certified allergy specialists at Black & Kletz Allergy have 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. The allergy specialists at Black & Kletz Allergy are extremely knowledgeable about the most current treatment options for patients with vocal cord dysfunction, asthma, and related conditions and can promptly answer any of your questions. The allergy specialists at Black & Kletz Allergy diagnose and treat both pediatric and adult patients. 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 area for more than 50 years and we look forward to providing you with state-of-the-art allergy and asthma care in a welcoming and pleasant environment.

Thanksgiving and Food Allergies

Thanksgiving Day is usually a time when people gather with family and friends in order to be with each other, watch football, and of course, eat! Unless you or a family member has a food allergy, you may not think about food allergies or food sensitivities much. It is important however to be more than cognizant of the topic of food allergies especially if you are hosting a Thanksgiving Day celebration. One must learn that food allergies can be very serious and even fatal to some individuals. Cooking and preparing Thanksgiving Day food as well as collecting various dishes from other guests, which is commonly done during this holiday, must be taken very seriously with respect to food allergies and food sensitivities.

It is important to note that approximately 4% of adults and 5% of children in the U.S. have food allergies. The most common 8 food allergens are milk, egg, soy, wheat, peanut, tree nut, fish, and shellfish. These 8 foods cause nearly 90% of most food allergy reactions.

It should be noted that peanuts are not actually nuts because they grow from the ground and not from a tree. Peanuts are classified as legumes and are closely related to other legumes such as beans (e.g., black, lima, navy, kidney, pinto, fava, lupin, mung, soybeans), chickpeas (i.e., garbanzo beans), lentils, and peas. Most allergists instruct their peanut allergic patients to avoid all legumes in addition to avoiding peanuts.

Knowing the above information, the person hosting a Thanksgiving holiday celebration should ask their guests if they have a food allergy or food sensitivity. They should also inform their guests who are preparing and/or bringing food to the host/hostess’ house about any food allergies or food sensitivities that any of the guests have so they can provide a list of ingredients used in their dishes. The goal is to make sure that the food-allergic or food-sensitive individual does not ingest any of the offending food allergen on purpose or accidentally.

When one thinks of Thanksgiving, the food most thought of is turkey. Although a turkey allergy is not very common, it is more common to have individuals experience sleepiness or fatigue after eating turkey meat. This adverse reaction to turkey is not an allergy, but classified as a food sensitivity to the amino acid “L-tryptophan.” L-tryptophan is found in high levels in turkey meat. The L-tryptophan travels from the gastrointestinal tract to the brain where it is converted to a serotonin. It is this chemical, serotonin, that is responsible for causing this sleepiness or fatigue.

There are 2 other common food sensitivities that should be known to all. The first food sensitivity is called “lactose intolerance.” It occurs when the body is unable to fully digest the sugar called lactose which is commonly found in milk and dairy products. This inability to break down lactose is due to a lack or decreased amount of the enzyme lactase. Lactose intolerance may cause gastrointestinal side effects such as abdominal bloating, abdominal pain, nausea, and/or diarrhea in affected individuals. The second food sensitivity one hears a lot about recently is called “gluten intolerance” or “gluten sensitivity.” No one is exactly sure of the mechanism of gluten intolerance but individuals with this condition experience abdominal bloating, abdominal pain, nausea, diarrhea, and/or constipation after eating foods containing gluten (i.e., wheat, barley, rye). Some patients also complain of fatigue and headaches as well. The symptoms resemble individuals with wheat allergy (i.e., celiac disease) and/or irritable bowel syndrome. Unlike celiac disease, however, gluten sensitivity does not cause damage the intestines.

The gravy used for turkey and mashed potatoes commonly contains dairy (e.g., milk), wheat, and/or soy. It is important to remember that tiny amounts of a food allergen may be all that is necessary to cause a severe allergic reaction is a sensitive individual. One must be careful about every ingredient in a food or dish.

Common food allergens such as milk, egg, soy, wheat, nuts, and peanuts are often found around the Thanksgiving Day table. Tree nuts are frequently found on string beans as well as in some types of stuffing.  Tree nuts and peanuts are common in many desserts such as brownies, cookies, cakes, and pecan pie.  Eggs and milk (i.e., dairy) are also used in many baked goods.  Although pumpkin allergies are not common, pumpkin pie may contain an assortment of ingredients that may trigger a food allergy in susceptible allergic individuals.  Many families incorporate a multitude of ethnic foods in their celebrations.  These cultural foods may not be traditional, but they increase the possibility of other allergenic foods such as fish and shellfish to be the causative agent of an approaching food allergy.  If someone has a serious food allergy, it is sensible for that person to bring their own food rather than eat food in which they are not 100% sure of its ingredients and origin.

The board certified allergists at Black & Kletz Allergy have been diagnosing and managing food allergies, other allergies, and asthma for more than 50 years in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We have convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Each office has on-site parking. The Washington, DC and McLean, VA offices 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. Please call for an appointment if you would like a consultation with one of our allergists, or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy prides itself in providing quality allergy and asthma care to the Washington, DC, Northern Virginia, and Maryland metropolitan area community.