Blog

Sinusitis vs. Allergies

• November 14, 2018
• BY BLACK & KLETZ ALLERGY

Many individuals are unsure whether they have sinusitis (i.e., sinus infection) vs. typical “allergies.”  Sinusitis generally refers to infected sinuses, however, sinusitis technically means “inflammation of the sinuses.”  Typically, sinusitis is a direct result of either a “cold” or allergies (i.e., allergic rhinitis, hay fever).  The symptoms of each condition are usually very similar and the differences can be very subtle, however there are several things to look at in order to help differentiate between the two disorders.  In both allergic rhinitis and sinusitis, most patients will experience one or more of the following symptoms: nasal congestion, runny nose, post-nasal drip, sneezing, itchy eyes, and/or watery eyes.  Patients with sinusitis, however, may also experience one or more of the following symptoms in addition to the symptoms above: sinus headaches, thick discolored mucus from the nose, sore throat, cough, sinus pressure, teeth pain (particularly the upper teeth), fatigue, malodorous breath, decreased sense of taste/smell, and/or mild fever.

When someone develops a sinus infection, it may be acute, chronic, or recurrent:

Acute sinusitis is the most common form of sinusitis.  It is the classic example of a sinus infection. Individuals typically will complain of sinus or facial pressure, headaches, nasal congestion, thick discolored nasal mucus, post-nasal drip with or without a sore throat, and/or cough.  Patients often will say that they had a “cold” before the sinus infection began. Others will give a history of being exposed to something that they were allergic to such as pets, pollens, dust, etc. The treatment may entail the use of antibiotics (generally if the symptoms have been present for more than 1 week), nasal corticosteroids, antihistamines, decongestants, and/or mucolytics (i.e., mucus thinners).  It should be noted that most cases of acute sinusitis are caused by viruses and thus antibiotics are not necessary. If the symptoms persist and/or get worse, however, antibiotics are often used.

Chronic sinusitis is not as common as acute sinusitis, but is generally more difficult to treat.  An allergist should suspect chronic sinusitis when the patient has had symptoms for a long time, a sinus infection is recurrent, and/or fatigue becomes more prevalent.  The symptoms of chronic sinusitis may include all of the symptoms found with acute sinusitis except a fever is less common with chronic sinusitis. In addition to the symptoms found in acute sinusitis, patients with chronic sinusitis may exhibit a decreased sense of taste/smell, fatigue, malodorous breath, and/or cough.  The cough tends to be a “barky” cough, although any cough may occur. The diagnosis of chronic sinusitis is usually verified by a CT scan of the sinuses. It will show thickened mucus membranes of the sinuses compared with an “air-fluid level” found in patients with acute sinusitis. In addition to using antihistamines, nasal corticosteroids, decongestants, and/or mucolytics, the treatment of chronic sinusitis generally involves a 30 day course of antibiotics.  If the infection is recalcitrant, another 30 day course of an antibiotic may be necessary. In some individuals, sinus surgery may be necessary in order to eradicate the infection. The surgical procedure may also be directed at creating better drainage of the sinuses, in order to help prevent future sinus infections.

Recurrent sinusitis is actually repetitive acute sinus infections.  They can occur for a variety of reasons, some of which are as follows:

1.) If an acute sinus infection is not completely eradicated, the focus of the bacterial infection remains, and the bacteria may grow back causing another acute sinus infection.

2.) The wrong antibiotic or an antibiotic that the bacteria is not as sensitive to may cause a sinus infection to return.

3.) Allergic patients that have been exposed and re-exposed to large amounts of allergen(s) can develop recurrent sinus infections.

4.) Re-exposure to different viruses may cause recurrent sinusitis

5.) Individuals with immune dysfunctions may develop recurrent sinusitis.

It is important to note that many individuals think that they are experiencing recurrent sinus infections, when in fact they have an indolent chronic sinus infection with intermittent worsening symptoms.  This gives the patient the false impression that they are getting recurrent acute sinus infections. It takes a board certified allergist in order to realize that the individual may have a chronic sinus infection instead of recurrent infections, as the treatment of the 2 conditions is very different.  The treatment of recurrent sinusitis is essentially the same as that of an acute sinus infection.

The board certified allergists at Black & Kletz Allergy have expertise in diagnosing and treating all types of sinus infections, as well as all types of allergic conditions and asthma.  We are board certified to treat both adult and pediatric patients and 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 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.  If you suffer from allergies and/or sinus-related symptoms, we are here to help alleviate or hopefully end these unwanted symptoms that have been so bothersome, so that you can enjoy a better quality of life.  Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

Treatments for Food Allergy

• October 24, 2018
• BY BLACK & KLETZ ALLERGY

Approximately 15 million Americans are affected by some form of food allergy and nearly 6 million of those are children under 18 years of age.  Many epidemiological studies indicate that the prevalence (i.e., the proportion of individuals in a population having the condition) of food allergy is increasing over the past 2 decades.  Genetic and possibly environmental factors predispose individuals to the development of many allergic disorders including food sensitivity.

Though a large number of foods can cause allergic reactions, in the United States, milk, egg, and peanut are the 3 most common allergenic foods.  Current management strategies require strict avoidance of these foods. Despite the intent of strict avoidance, accidental ingestion of allergenic foods can and does happen.  This may result in a severe reaction which may require the use of a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick). An individual who is susceptible to severe food allergies may result in considerable anxiety which may impact the quality of life of that individual as well as their families.

Several clinical trials are now looking at various treatment options in an attempt to reduce the risk of severe reactions with accidental exposures.  These involve different types of gradually increasing exposures to foods at regular intervals under controlled conditions.

1. Desensitization:  An increase in reaction threshold to a food allergen while receiving active treatment.
2. Sustained unresponsiveness:  A lack of a reaction to a food allergen after active therapy has been discontinued after a period of time.  It requires some level of continued allergen exposure.
3. Remission:  A temporary state of non-responsiveness off therapy.
4. Oral tolerance:  A complete lack of clinical reactivity to an ingested food allergen.  It does not depend on continued food allergen exposure.

Several types of immunotherapy, including oral immunotherapy (OIT), sublingual immunotherapy (SLIT), and epicutaneous immunotherapy (EPIT), are under active investigation for the treatment of food allergy.

1. Oral Immunotherapy:  This form of immunotherapy requires the daily ingestion of an allergen powder (e.g., peanut protein along with lipids and carbohydrates) that is mixed with another food and ingested.  OIT involves treating patients with escalating doses of the offending food, with the hope of slowly inducing desensitization to that food. Adverse reactions of this therapy may include systemic reactions, gastrointestinal symptoms, and/or skin manifestations.  Some trials have demonstrated that the use of anti-IgE (i.e., Xolair (omalizumab) with OIT will allow updosing to proceed more quickly and with fewer allergic side effects. Other studies are also investigating whether adding adjuvants such as probiotics to peanut can increase the efficacy of the therapy.
2. Sublingual Immunotherapy:  This therapy requires the application of an allergen extract in the sublingual space (held under the tongue for 2-3 minutes and then swallowed) on a daily basis over the time of treatment.  SLIT is well tolerated with minimal side effects that are typically limited to oropharyngeal itching or tingling.
3. Epicutaneous Immunotherapy:  This approach involves the application of a small allergen patch to the back or upper arm.  The patches are changed at 24-hour intervals over years of therapy. EPIT is generally well tolerated.  Typically, only mild skin irritation is noted at the patch site for the majority of patients.

In comparing the different types of immunotherapy for food allergy, OIT has the greatest amount of clinical desensitization, followed by SLIT and then EPIT.  Allergic side effects to the different treatments are in the same order with OIT having the most allergic side effects.

Despite the 3 types of desensitization methods that are utilized for food allergies, there are still gaps in our knowledge and unanswered questions to be answered:

1. The optimal dose, frequency, and duration of OIT are unknown.
2. Is maintenance therapy or food ingestion required to maintain remission?  If so, at what dose and what frequency?
3. Is a combination or sequence of either OIT, SLIT, and/or EPIT better than one treatment alone?

Though these treatment options are not yet approved by the FDA, the future looks promising for the treatment of food allergies as research continues to answer some of previous unanswered questions.

The board certified allergists at Black & Kletz Allergy have been diagnosing food allergies in both adults and children for over 5 decades.  As of yet, there are no FDA-approved methods to treat food allergies, although several methods are being researched at this time.  As of now, the gold standard approach to treat food allergies is to strictly avoid the offending food. It is very important to identify the specific food that one is allergic to in order to avoid it in the future.  Black & Kletz Allergy has 3 office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The allergy specialists are able to test for most foods and can be done by either blood tests or allergy skin tests.  We offer onsite parking at each one of our locations and both 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 feel you may have a food allergy and/or a food intolerance, please call us today to schedule an appointment. Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy are eager to help you find out if you are allergic to foods and to identify which ones.  This will allow you live in less fear by avoiding the offending food as well as have a detailed plan on what to do if you would accidentally ingest the given food.

Histamine Fish Poisoning

• September 24, 2018
• BY BLACK & KLETZ ALLERGY

Histamine is the chemical that is responsible for most allergy-related symptoms. It is usually stored inside cells called mast cells.  When one is exposed to allergens that he or she has been previously sensitized to, (e.g., pollens, dust mites, molds, animals, certain foods), the preformed specific antibodies react with their proteins (i.e., antigens) which cause a release of histamine and other similar substances from the mast cells into the tissues of the body.  These chemicals in turn trigger various symptoms such as itching, sneezing, wheezing, coughing, runny nose, watery eyes, nasal congestion, post-nasal drip, etc.

Fish is one of the most common foods that cause food allergies.  Sensitive individuals may experience allergic reactions after consuming fish.  The classic mechanism of this type of allergic reaction is caused by antigen-antibody interactions.  However, there are some people who are not sensitized or allergic to fish but can experience similar symptoms after eating fish.  In these individuals, the symptoms are brought on by a different mechanism.

Many types of fish naturally contain a chemical called histidine.  When the fish are not properly stored and refrigerated, bacteria overgrowth occurs in and on the fish.  These bacteria release an enzyme called histidine decarboxylase which converts the naturally occurring histidine in the fish to a chemical called histamine.  The enzyme is resistant to freezing and heating and can persist even after the bacteria are eliminated by normal cooking techniques. The resulting high levels of histamine cause the same symptoms as an allergic reaction, but the underlying mechanism is a type of toxicity rather than a true allergy.

This condition used to be called scombroid fish poisoning, as fish belonging to Scombridae family (e.g., tuna, mackerel, marlin, swordfish) were originally implicated.  Later, many other non-scombroid fish such as mahi-mahi, sardine, herring, anchovy and bluefish were also found to cause this condition. The preferred current terminology is called “acute histamine toxicity.”

The symptoms usually begin 30 minutes to 2 hours after eating the fish.  The most common manifestations may include:

1. Generalized itching
2. Reddish rash over the neck, upper torso, and/or upper extremities
3. Throbbing headache
4. Nausea, vomiting, abdominal cramps, and/or diarrhea
5. Palpitations and/or dizziness
6. Anxiety and/or chest tightness
7. Swelling of the face and/or the tongue
8. Difficulty in breathing

The diagnosis is usually made from the patient’s history.  The appearance of the fish is sometimes described as honeycombed. Some affected individuals also experience a sharp, metallic, bitter, and peppery taste while eating the fish.  Laboratory tests are usually not helpful as histamine is rapidly degraded and cannot be detected in blood or urine samples within 1 to 2 hours after the onset of symptoms. The presence of a specific IgE antibody in the blood to the fish usually indicates an allergic reaction and not a toxic reaction due to the high levels of histamine.  Clusters of individuals exhibiting similar symptoms after eating the same meal generally points more to histamine poisoning rather than an allergic reaction.

The treatment of this condition involves medications that focus on the relief of symptoms. Antihistamines [H-1 blockers (e.g., Benadryl, Claritin, Allegra, Zyrtec) along with H-2 blockers (e.g., Zantac, Tagamet)] are useful in relieving the itching and rash.  Corticosteroids may be appropriate in certain more severe situations. Bronchospasm which may cause wheezing, shortness of breath, chest tightness, and/or coughing can be treated with albuterol inhalations. Rarely, some people may also need intravenous hydration.  Fortunately, most cases of histamine toxicity are self-limited and the symptoms often resolve spontaneously within 6 to 8 hours.

The prevention of acute histamine toxicity requires proper and continuous refrigeration of fish until the time of cooking.  This should prevent bacterial overgrowth and likewise the conversion of histidine to histamine.

The board certified allergists at Black and Kletz Allergy have 3 convenient locations [Washington, DC; McLean, VA (Tysons Corner, VA); Manassas, VA] in the Washington, DC metropolitan area.  The allergy doctors have been trained in providing allergy care for both adults and children.  They in fact have been diagnosing and treating adults and children with allergies for more than 50 years.  They will promptly answer any questions you may have regarding food allergies, food sensitivities, food toxicities, and related disorders.  The allergy specialists can also help you with other allergic conditions such as asthma, hives, swelling episodes, insect sting allergies, medication allergies, contact dermatitis, generalized itching, eczema, sinus disease, anaphylaxis, eosinophilic disorders, and immune disorders.

All 3 offices of Black & Kletz Allergy offer on-site parking.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between our McLean office and the Spring Hill metro station on the silver line.  Please call our office to schedule an appointment or alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day.

Grass-Induced Allergic Reactions

• August 24, 2018
• BY BLACK & KLETZ ALLERGY

As we enter the grass season in the Washington, DC, Northern Virginia, and Maryland metropolitan area, it is interesting to note that grasses can cause a multitude of symptoms.  These symptoms may vary from mild to severe and are most notable from the months of May through July in the mid-Atlantic region.  Grasses have been implicated in a variety of disorders ranging from allergic rhinitis (i.e., hay fever), allergic conjunctivitis, asthma, urticaria (i.e., hives), pruritus (i.e., generalized itching), angioedema (i.e., swelling episodes), and anaphylaxis.

The most common disorder caused by exposure to grasses is allergic rhinitis.  Individuals with this condition experience symptoms which may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, sore throat, sinus congestion, sinus headaches, fatigue, and/or snoring.

Allergic conjunctivitis is manifested by itchy eyes, watery eyes, swollen eyes, and/or redness of the eyes.  It is not unusual for individuals with allergic conjunctivitis to experience the feeling of their eyes sticking together from copious amounts of discharge from the eyes.  Rarely, photophobia (i.e., sensitivity to light) may occur in severe cases.

Grasses may also exacerbate asthma symptoms in asthmatic patients.  These patients may experience wheezing, shortness of breath, coughing, and/or chest tightness when exposed to grass pollen.  Many of these individuals find it even more difficult to exercise outside when the grass pollen count it high. Such individuals should be encouraged to minimize their exposure to grass pollen as asthma may be life-threatening in severe cases.

Occasionally grass-allergic patients may develop itchy hives when exposed to high levels of grass pollen and/or when an individual’s skin comes in contact with grass.  These highly grass-allergic patients should be advised to avoid contact with grass, as occasionally the hives can progress to more severe life-threatening symptoms. People who play sports on grassy areas are particularly at risk for this type of reaction.

Similar to patients that develop hives on contact with grasses is a condition where individuals develop generalized itching of their skin without the accompanying rash or hives.  These patients should take the same precautions as the allergic individuals who develop hives from grass exposure.

Another related disorder that may occur upon exposure to grass is called angioedema.  Individuals with this entity may develop swelling of different body parts that either come in direct contact with grasses or are exposed to grass pollen by indirect contact.  Angioedema is a very serious sign, particularly since the swelling may occur internally, such as in the throat, which may obstruct an individual’s breathing. Patients with this disorder should be prescribed and taught how to use a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick).  If used, the patient is to go immediately to the closest emergency room.

On rare occasions a highly grass-sensitive individual may be exposed to an abundance of grass or grass pollen and develop anaphylaxis.  Activities that cause grass stains on the skin (e.g., football, rugby) are more likely to cause anaphylaxis then other activities where hard direct physical contact with grass is not common (e.g., tennis, basketball).  In any case, anaphylaxis is a medical emergency and anyone with anaphylaxis should be treated with epinephrine and be followed up immediately at the closest emergency room. It is imperative that these individuals carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick).

As one can see from the examples above, grasses may cause many different symptoms among a variety of conditions.  The symptoms may be mild, moderate, or severe. The board certified allergists at Black & Kletz Allergy have been treating individuals with grass allergies for over 50 years.  If you suffer from any of the symptoms above in the Spring or Summer, please call our office for an allergy consultation in order for us to determine if you have grass or other allergies that may cause any of the symptoms above.  We have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area with office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  Black & Kletz Allergy specializes in treatment of both pediatric and adult patients.  Alternatively, to schedule an appointment, you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergists at Black & Kletz Allergy pride themselves in providing superior allergy and asthma care in a professional and compassionate environment.

Exercise-Induced Asthma

• July 24, 2018
• BY BLACK & KLETZ ALLERGY

“Exercise-induced asthma” or “exercise-induced bronchospasm” is a condition in which individuals develop asthma symptoms only when exercising.  The bronchial tubes become narrowed making it difficult to move air out of the lungs. If one has chronic asthma however, one can still have their asthma triggered by exercising, but in addition, their asthma may be exacerbated by other factors such as allergies (e.g., dust mites, cockroaches, pets, molds, pollens), upper respiratory tract infections, cold air, hot air, increased or decreased humidity, cigarette smoke, diesel fumes, strong scents, and other irritants.  Many individuals with exercise-induced asthma are not diagnosed in a timely fashion since many clinicians do not recognize the condition.  It may go undiagnosed for years and the symptoms may be attributed to poor exercise tolerance or just being “out of shape.” Children often avoid exercise without telling anyone that exercise is bothersome.

The classic symptoms of exercise-induced asthma include wheezing, chest tightness, coughing, and/or shortness of breath.  Individuals with exercise-induced asthma generally develop asthma symptoms within 5 to 20 minutes after beginning their exercise.  It is also typical for them to have symptoms after they stop exercising. Exercise-induced asthma tends to occur more often on cold, dry days rather than on warm, humid days.

The diagnosis of exercise-induced asthma is made by way of a comprehensive history and physical examination in conjunction with pulmonary function tests.  It is also helpful for the patient to have a peak flow meter to use at home so that he or she can measure their outflow of air before and after exercise. A decrease in the peak flow while or after exercising helps the allergist determine if the patient is exhibiting an exercise-related decrease in air flow.  Other conditions that should be ruled out include cardiac disease, GERD (i.e., acid reflux), chronic sinusitis, chronic obstructive pulmonary disease [COPD (e.g. chronic bronchitis, emphysema)], anxiety attacks, and vocal cord dysfunction, to name a few.

Although patients with exercise-induced asthma develop symptoms upon exercise, it is important that the patient understand that with treatment, it is usually possible to exercise.  In fact, exercise is generally encouraged in almost all individuals with this condition. There are many examples of famous athletes who have won Olympic Gold Medals, football championships, etc. that have had exercise-induced asthma.  It may be helpful for the some individuals to get an asthma action plan from their allergist so that he or she knows exactly what to do to treat or prevent the symptoms. In addition, the use of a short-acting beta-2 agonist rescue inhaler medication such as albuterol e.g., (Proventil, Ventolin, ProAir, Xopenex) about 30 minutes before exercise may prevent symptoms from developing.  If needed, the inhaler may also be used after symptoms occur if this plan is discussed and agreed upon with an allergist. There are other medications which can be utilized such as Singulair (i.e., montelukast) which have been shown to help prevent the symptoms of exercise-induced asthma. More severe cases may need inhaled corticosteroids in order to control the condition. In addition to medications, warm-ups and cool-downs may mitigate or even prevent symptoms.  It is also prudent to avoid exercising in the high pollen season if the individual is allergic to pollens. Avoidance of exercise is also recommended if the person is experiencing an upper respiratory tract infection or if the air is cold and dry.

The board certified allergy specialists at Black & Kletz Allergy are always available for our patients to ask any questions that they may have regarding asthma or allergies.  We have been treating pediatric and adult patients with exercise-induced asthma, as well as patients with chronic asthma, allergic rhinitis (i.e., hay fever), allergic skin conditions such as eczema and hives, insect sting allergies, medication allergies, eosinophilic disorders, other allergic maladies, and immune disorders for more than 5 decades.  We have 3 office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer 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 would like to be evaluated today for exercise-induced asthma or any other allergic or immunologic problem, please call us today.  You may also click Request an Appointment instead and we will respond to your request within 24 hours by the next business day.  The allergists at Black & Kletz Allergy pride ourselves in providing the highest quality asthma and allergy care in the Washington, DC metro area.

Mold Allergies and How They Can Affect You

• June 24, 2018
• BY BLACK & KLETZ ALLERGY

Molds are fungi that grow in the form of multicellular filaments that are called hyphae.  Fungi that grow in a single celled environment are called yeasts. Mildew is also a fungus that closely resembles mold; however, the color of mildew tends to be white whereas mold tends to be black, blue, green, or red.  Regardless, mold, mildew, and yeast can all play havoc to individuals who are either sensitive or allergic to them. Mold and mildew produce unwanted odors that many individuals find offensive or downright problematic as they can cause ailments to those exposed.

The physical appearance of molds usually is recognized by a discoloration and fuzziness presentation.  Molds can be found anywhere outdoors or indoors and are typically found on old or expired foods, rotten decaying debris (e.g. wet fallen leaves in the Fall, compost piles, grasses, rotting wood), and in places where increased moisture or water exists (e.g., basements, bathrooms, kitchens).  Molds produce mold spores which are their tiny microscopic reproductive structures. The size of a mold spore generally ranges from 3 to 45 microns in diameter which is less than half the width of a human hair. These spores begin to germinate and multiply. The spores multiply by producing reproductive hyphae.  They and are released into the air and given their microscopic size, they are able to float in the air sight unseen. Mold spores can grow in any environment with a constant source of moisture. There are even types of molds that can survive in very arid conditions such as deserts. During the growth process, mold spores begin to undergo chemical reactions that allow them to consume nutrients and further multiply.  These chemical reactions cause fumes to be released into the atmosphere. These fumes are responsible for the unpleasant musty mold odor. Of note, there are over 400,000 types of molds.

In the Washington, DC, Northern Virginia, and Maryland metropolitan area, the numbers of mold spores in the environment are generally higher than in many other parts of the country.  Washington, DC was built on a swamp. In addition, the Washington, DC metropolitan area tends to have a fairly high relative humidity when compared to many other areas of the U.S.  This combination exposes the residents of our metro area to a higher concentration of molds. In turn, it places us at a greater risk to develop mold allergies and other non-allergic mold-related conditions that may occur in sensitive individuals.  Non-allergic mold-related illnesses may result from either the growth of pathogenic molds within the body or from the effects of ingested or inhaled toxic compounds called mycotoxins which are produced by molds. The molds that produce mycotoxins can pose serious health risks to humans and animals.  Some studies claim that exposure to high levels of mycotoxins can lead to neurological problems and prolonged exposure may be particularly harmful. The research on the health effects of these types of molds has not been conclusive. The term “toxic mold” refers to molds that produce mycotoxins, such as Stachybotrys chartarum and not to all molds in general.

Mold allergies are very common and the symptoms are the same as other causes of hay fever (i.e., allergic rhinitis) and/or asthma.  The symptoms may include runny nose, sneezing, nasal congestion, post-nasal drip, itchy nose, itchy eyes, watery eyes, redness of the eyes, sinus headaches, wheezing, coughing, chest tightness, and/or shortness of breath.  Symptoms often worsen when a sensitive individual is in a damp or moldy environment such as a basement or crawl space.

Approximately 1-2% of patients with asthma have an allergic or hypersensitive reaction to a type of mold known as Aspergillus fumigatus.  Similarly, 2-15% of children with cystic fibrosis have the same reaction to this mold.  Aspergillus fumigatus is generally found in the soil.  Asthmatics and cystic fibrosis patients with that react to this mold have a condition called allergic bronchopulmonary aspergillosis (ABPA).  ABPA is more common in adolescents and male individuals.  The symptoms of ABPA are very much the same symptoms of asthma; however they may also cough up mucus with brownish flecks and may also have a mild fever.  The diagnostic workup may include radiographic studies, bloodwork, sputum culture, pulmonary function tests, and allergy skin testing. The treatment may involve the use of oral corticosteroids and/or antifungal medication in addition to the typical asthma medications such as corticosteroid inhalers, long-acting beta agonists, leukotriene antagonists, short-acting beta agonists, and/or theophyllines.

The diagnosis of mold allergy is done by a board certified allergist who will do a comprehensive history and physical examination.  Allergy testing to molds can be done via skin testing or blood testing.

Treatment of mold allergy should always begin by trying to prevent exposure to mold.  There are many things that can be done in one’s home or workplace that may help reduce one’s exposure.  Reducing the humidity, fixing any leaks, wearing a mask when doing yardwork, limiting outdoor activities when the mold counts are high, using air conditioning with a HEPA filter, installing a dehumidifier, and removing carpeting from places where it can get wet are some of the ways to reduce mold exposure.  The allergist may prescribe allergy medications (e.g., antihistamines, decongestants, nasal corticosteroids, nasal antihistamines, eye drops, leukotriene antagonists, asthma inhalers) to help alleviate one’s symptoms. Allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization) are extremely effective in the treatment of mold allergy.  They are effective in 80-85% of the patients who take them. They have been utilized in the U.S. for more than 100 years and get more to the root of the underlying problem by causing an individual to develop protective antibodies against mold as well as other allergens (e.g., pollens, dust mite, pets, cockroach).

The board certified allergists at Black & Kletz Allergy have 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area.  Our offices are located 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 also Metro accessible.  The McLean office has a complementary 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 make an appointment, please call our office or you may 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 helping patients with mold allergies and other causes of hay fever, asthma, hives, sinus disease, eczema, food allergies, medication allergies, insect sting allergies, and immunological disorders for more than half a century.  If you suffer from mold allergies or any other type of allergies it is our mission to improve your quality of life by reducing or preventing your undesirable and irritating allergy symptoms.

Chronic Sinusitis

• June 24, 2018
• BY BLACK & KLETZ ALLERGY

Sinuses are air filled cavities within the facial bones.  They are located behind the forehead (e.g., frontal), behind the eyes (e.g., ethmoid, sphenoid), and behind the cheek bones (i.e., maxillary).  The membranes lining the inside of these cavities secrete mucus which normally drains into the nasal cavity through small openings.

When the nasal cavity becomes inflamed (i.e., rhinitis) either due to allergen or irritant exposure or due to microbial infections, the pores through which the sinuses drain can become clogged.  This clogging of the pores may lead to the back up of secretions within the enclosed sinus cavities. Accumulation of mucus within the sinuses can result in proliferation of viruses and bacteria and can lead to chronic sinus infections (i.e., chronic sinusitis), defined as persisting sinus-related symptoms lasting for more than 12 weeks.

The common symptoms of a chronic sinus infection or chronic inflammation of the sinuses may include facial pressure/pain, headache, discolored nasal and post-nasal secretions, cough and/or malaise.  The diagnosis of this condition requires a detailed history of onset and progression of specific symptoms, a physical examination, and imaging studies such as sinus X-rays and/or CT scans.

Some common medical treatments of chronic sinusitis are as follows and may include combinations of the treatment regimens listed below:

1. Saline nasal sprays and/or irrigations:  These are useful in the mechanical clearance of irritants, allergens, and microbes from nasal and sinus cavities.  They are inexpensive and easy to use although they can cause some discomfort during usage is some individuals. Their main use is as an adjunctive therapy to other more specific treatments.
2. Topical steroid sprays:  These are considered first-line treatments for chronic sinusitis.  They act by controlling inflammation and reducing the swelling of the tissues and decreasing excessive secretions. They are useful both in chronic sinusitis with nasal polyps and chronic sinusitis without polyps.  They are widely available and easy to use. Some of the potential drawbacks of topical steroids may include a burning sensation of the nose, headaches, sore throat, and/or occasional nosebleeds.
3. 3. Topical antibiotics:  These are sometimes useful in local treatment of bacterial infections.  The effects are usually short-lived. These agents are not currently recommended for routine use but offer the potential for improved directed treatment as the ability to identify the effects of specific pathogens evolves.
4. 4. Surfactants:  Some clinical trials demonstrated benefits of surfactants in the control of biofilms.  Surfactants are widely used as detergents, emulsifiers, foaming agents and dispersants in the cosmetics, hygiene, food, and oil industries. Their use in the medical field is also common, particularly within the field of wound care.  Many wound cleansers contain surfactants and help in the enhancement of wound closure. Their use however can be associated with considerable discomfort and their role in management of chronic sinusitis is not clearly determined at this time.
5. Oral steroids:  They can effectively reduce inflammation and are especially useful for shrinking nasal polyps, though they also may result in the multisystem improvement of symptoms.  Due to their significant systemic side effects (e.g., weight gain, endocrine dysfunction, thinning of bones, peptic ulcers, cataract formation, depression), they are utilized judiciously and only for short periods of time.
6. Oral antibiotics:  These are often used to control acute flare-ups of bacterial infections.  Some classes of drugs such as macrolides [(e.g., Biaxin (clarithromycin), Zithromax (azithromycin), erythromycin] also have anti-inflammatory effects in addition to their antibacterial properties.  Potential side effects include gastrointestinal distress and possible development of bacterial resistance on repeated usage.
7. Biologicals:  As more research sheds light on specific inflammatory molecules and pathways driving the inflammation in chronic sinusitis (i.e., phenotypes and endotypes), biological medications can offer targeted and more effective treatment options.  The potential advantages are the reduced need for oral or topical steroids as well as the need for sinus surgery. A few of these agents are currently being used for the control of asthma but none of them have been currently approved for chronic sinusitis.

Preventive measures for chronic sinusitis include identification of specific allergen sensitivities by allergy testing by a board certified allergist.  Allergy testing can be done by skin testing or blood testing depending upon the circumstance and age of the patient.  The aggressive treatment of allergic seasonal and/or perennial rhinitis (i.e., hay fever) promotes proper sinus drainage and improves upper airway function.

The board certified allergists and immunologists at Black & Kletz Allergy have 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland  metropolitan area.  Our allergists have been treating chronic sinusitis as well as acute sinusitis and other sinus-related conditions for many years.  Our offices are located 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.  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 an allergic condition that predisposes you to sinus problems or sinus infections, 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 specialists at Black & Kletz Allergy have been treating both adults and children in the Washington, DC metropolitan area for allergies, asthma, sinus disease, and immunologic disorders for more than 50 years and would be happy to provide allergy and sinus relief for you in a caring and professional atmosphere.

Chronic Cough

• May 24, 2018
• BY BLACK & KLETZ ALLERGY

The common cold is the most common cause of a cough.  It usually subsides spontaneously after 2 to 3 weeks. However, a persistent cough may be the first sign of a more serious disease process.

A chronic cough (defined as lasting for more than 8 weeks in adults and more than 4 weeks in children) is one of the most common presenting complaints in ambulatory medical clinics across the country, according to the Centers for Disease Control (CDC).

Though they are a number of different causes for chronic cough, 4 conditions account for the vast majority of cases:

1. Upper airway cough syndrome (i.e., UACS, previously called “post-nasal drip syndrome”)
2. Gastroesophageal reflux disease (i.e., GERD or acid reflux) / Laryngo pharyngeal reflux (i.e., LPR)
3. Asthma
4. Eosinophilic bronchitis.

Additional causes may include:

1. Side effects of medications such as ACE (i.e., angiotensin converting enzyme) inhibitors which are typically utilized to treat high blood pressure
2. Tobacco use
3. COPD (i.e., chronic obstructive pulmonary disease) which encompasses both emphysema and chronic bronchitis
4. Sleep apnea

An excessive or chronic cough can seriously impair the quality of life of an individual and lead to vomiting, muscle pain, rib fractures, urinary incontinence, fatigue, syncope, and/or depression.  Some of the “red flags” indicating a more serious issue may include an association of a cough with fever, weight loss, hoarseness, and/or blood in the sputum. When a cause is not obvious, a chest X-ray is usually obtained to rule out common infections, inflammatory conditions, and/or tumors.

UACS:  It is the most common cause of chronic cough.  The condition is a result of inflammation of the tissues inside the nasal cavity (i.e. allergic or non-allergic rhinitis).  The symptoms may include runny nose, nasal congestion, sneezing, and/or post-nasal drip but their absence does not exclude UACS.  Physical examination may reveal a pale and moist lining of the nasal cavity, swelling of turbinate tissues, redness and/or a cobblestoning appearance in the back of the throat.  Apart from specific treatments of identifiable causes, the symptoms can be relieved by a combination of decongestants, antihistamines, nasal sprays (e.g., saline, corticosteroids, antihistamines, anticholinergics).  Improvement in symptoms can take a few weeks after the initiation of treatment.

Asthma and/or COPD:  Close to one fourth of all cases of a chronic cough may be due to asthma.  The diagnosis is suspected when a cough is associated with chest tightness, shortness of breath, and/or wheezing.  However, a cough may be the only manifestation of asthma in some instances (i.e., cough variant asthma). The diagnosis is established by spirometry before and after the inhalation of a bronchodilator medication.  If inconclusive, asthma can be provoked by inhalation of a medication called methacholine, as part of a diagnostic work-up. Treatments may include inhaled corticosteroids, inhaled bronchodilators, oral anti-inflammatory medications, and rarely short courses of oral corticosteroids.  Cough and other asthma symptoms usually respond to therapy in less than a week.

Signs and symptoms suggestive of asthma may also occur in persons with COPD. Spirometry is diagnostic, and purulent sputum production may also be present. Treatment usually includes an inhaled bronchodilator, inhaled anticholinergic, inhaled corticosteroid, and occasionally a 1-2 week course of oral corticosteroids (with or without antibiotics).

Non-asthmatic eosinophilic bronchitis:  This condition is characterized by a chronic cough without evidence of airflow limitation on pulmonary function tests but the presence of eosinophils in the sputum.  This condition does not respond to inhaled bronchodilators but does respond to inhaled corticosteroids. Avoidance strategies are recommended when the inflammation is due to occupational exposure or inhaled allergens.

GERD/LPR:  Suspicion for these conditions arise when symptoms of heartburn, regurgitation, sour taste, and/or hoarseness are associated with a chronic cough. Consensus guidelines recommend empiric therapy for at least eight weeks in conjunction with lifestyle modifications such as dietary changes and weight loss.

Obstructive sleep apnea:  Obstructive sleep apnea usually presents with night time snoring, restless sleep, and/or daytime somnolence, however, cough can be a manifestation is some cases.  CPAP machines help to relieve the obstruction by forcing air through the upper airways.

ACE inhibitors:  A cough may begin as a side effect in about 10 to 20% of patients receiving these medications and is more common in women.  The cough may appear several months after beginning an ACE inhibitor which often makes it more difficult to diagnose. The only treatment of a cough caused by an ACE inhibitor is the discontinuation of the ACE inhibitor.  After discontinuing the ACE inhibitor, it may take 1-2 months for the cough to subside.

Children:

The most common causes of a chronic cough in children 6-14 years of age are asthma, protracted bacterial infections, and UACS.  Bacterial bronchitis generally requires a 2 week course of an antibiotic such as Augmentin in children who are not allergic to penicillins or clavulinic acid, the components of Augmentin.  UACS is rare in children younger than 6 years of age. Exposure to tobacco smoke, pets, and environmental irritants should be minimized. Of note, rarer conditions such as foreign body aspiration, congenital malformations, and certain immune disorders can also cause a chronic cough in children.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating chronic coughs in both adults and children in patients in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  Patients are carefully screened for allergies, asthma, GERD, upper respiratory tract infections, medication usage, sinus disease, and other causes of a chronic cough.  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 a chronic or intermittent cough, 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 allergy doctors at Black & Kletz Allergy are confident that we will be able to help you identify the cause of your cough as well as treat the underlying condition in order to terminate your cough.