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New Targeted Treatments for Asthma

Asthma is a chronic inflammatory disorder of the lungs.  Genetics play a major role in the causation of the disease process.  It is a characteristically variable disease with the severity varying from person to person.  It also varies at different stages in one’s lifetime of an affected individual.  Environmental factors such as exposure to allergens, irritants, and infections are the usual factors that trigger exacerbations of asthma.

Even when symptoms are not present, low-grade inflammation is believed to exist in affected individuals.  In patients who are susceptible to frequent flare-ups of asthma, it has been well established that adequately controlling the ongoing inflammation will substantially reduce the frequency and severity of exacerbations.  Uncontrolled inflammation can also adversely affect the lung function in the long term.

Corticosteroids are global anti-inflammatory agents and have been the mainstay of maintenance therapy for several decades.  They are proven to suppress the inflammatory cascade at multiple points in a dose-dependent fashion.  They are very reliable in preventing flare-ups of asthma as well as preserving lung function.  However, long-term use of corticosteroids (especially in high doses) unfortunately is not without risks.  The potential side effects may include increased susceptibility to infections, thinning of bones, cataracts, glaucoma, increased appetite, weight gain, mood swings, glucose intolerance as well as many other adverse effects.  These side effects can be minimized by using these agents in the lowest effective dosage and for the shortest possible time.

Over the past several years, scientists have focused on developing alternatives to corticosteroids with fewer side effects.  Research has been fruitful in delineating various “pathways” in the causation and progression of inflammation.  Different chemical mediators mediate the process at different stages.  Blocking these mediators by specific drugs has proven to be effective in controlling the resulting inflammatory damage to tissues.

Leukotrienes were one of the earliest identified mediators for which blocking drugs were developed. Zileuton (i.e., Zyflo), zafirlukast (i.e., Accolate) and montelukast (i.e., Singulair) were approved by the U.S. Food & Drug Administration (i.e., FDA) for maintenance treatment of asthma in the late 1990’s.  These are oral medications used daily in patients with persistent asthma.  Zyflo works by inhibiting leukotriene formation whereas both Accolate and Singulair block the action of specific leukotrienes.  Though these drugs do not help everyone, they are very effective in asthmatics in which leukotrienes play a major role in perpetuating inflammation.  These agents do not have the steroid related side effects, however, a very small percentage of people using Singulair were noted to experience emotional disturbances such as depression.  In addition, patients taking Zyflo must have their liver function tests monitored while on the medication.

Immunoglobulin E (i.e., IgE) is the antibody that mediates allergic reactions and contributes to the disease frequency and severity of asthma exacerbations.  Omalizumab (i.e., Xolair) is a monoclonal antibody that depletes IgE in the blood and has been shown to reduce the frequency of symptoms and exacerbations in patients with asthma.  Note that it is also helpful in the treatment of recalcitrant chronic idiopathic urticaria (i.e., hives).  For asthma, it is given as an injection under the skin (i.e., subcutaneously) at a dose of 75 to 375 mg. every 2 or 4 weeks to patients 6 years of age and older.  The dose is calculated based on the serum IgE level and the weight of the patient and is given to patients with moderate to severe persistent asthma.  This medication is however unlikely to be helpful in patients with non-allergic asthma.  In the treatment of chronic idiopathic urticarial, Xolair is given subcutaneously at a dose of 150 or 300 mg. every 4 weeks to patients 12 years of age and older and is not dependent on the serum IgE level or body weight.

Eosinophils, on the other hand, are a type of white blood cell, long known to cause tissue damage when present in excessive numbers.  In a subtype of asthma, these cells play a predominant role in the inflammatory pathway.  Three “biological” medications were recently approved by the FDA for maintenance treatment of “eosinophilic” asthma.  These medications are effective in controlling asthma in patients who have high levels of eosinophils in their peripheral blood, detected in a commonly done test called a CBC (i.e., complete blood count).

Mepolizumab (i.e., Nucala) was approved in November of 2015.  It is a monoclonal antibody that blocks a molecule called IL-5 (i.e., interleukin-5) which is essential for growth and survival of eosinophils.  It is given as a subcutaneous injection at a fixed dose of 100 mg. every 4 weeks in patients 12 years of age and older who have severe persistent asthma.

Reslizumab (i.e., Cinqair) is another monoclonal antibody that received FDA approval in March of 2016. This medication is administered intravenously in a dose of 3mg. per kg. of body weight, every 4 weeks, infused over 20 to 50 minutes for patients with severe persistent asthma aged 18 years and older.

The most recent medication receiving approval for maintenance treatment of severe persistent asthma was benralizumab (i.e., Fasenra).  It was approved in November of 2017 for patients 12 years of age and older with the eosinophilic asthma phenotype.  It is injected subcutaneously in a fixed dose of 30 mg. The frequency of administration is once every 4 weeks for the first 3 doses and then once every 8 weeks thereafter.

The board certified allergy doctors 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 allergists at Black & Kletz Allergy are extremely knowledgeable about the most current treatment options for patients with asthma and related disorders and can promptly answer any of your questions.  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 excellent state of the art allergy and asthma care in a friendly and pleasant environment.

Allergies and Thanksgiving

It is that time of the year again when families and friends gather together for the highly anticipated Thanksgiving Day holiday.  Most people do not think about how Thanksgiving may affect one’s allergies, however, the holiday is full of potential triggers for many individuals prone to various allergies.

The most obvious allergies in relationship to Thanksgiving would be food allergies.  This relationship stems from the fact that when the average person thinks of Thanksgiving, they immediately associate the holiday with food and gluttony.  There are individuals who are allergic to turkey, the staple food of Thanksgiving, but turkey allergy is not very common.  More commonly, many individuals will experience sleepiness after eating turkey meat.  This phenomenon is explained due to the fact that turkey contains higher levels of the amino acid “L-tryptophan.”  L-tryptophan will enter the bloodstream from the digestive tract and travel to the brain where it gets converted to the chemical “serotonin.”  It is the serotonin that is responsible for causing this sleepiness.  In addition to turkey which helps fill the plates on a Thanksgiving Day dinner, there are lots of other foods that accompany this holiday favorite.  Common food allergens such as wheat, soy, egg, milk, nuts, and peanuts are often found around the table.  Gravy used for turkey and mashed potatoes frequently contains soy, wheat, and/or dairy.  Nuts are commonly found on string beans and in some types of stuffing.  Nuts and peanuts are common in many desserts such as pecan pie and brownies.  Eggs and milk (dairy) are also used in many baked goods.  Although pumpkin allergies are not common, pumpkin pie may contain an array of ingredients that may trigger a food allergy in susceptible individuals.  It is also important to note that among various cultures, many families incorporate many ethnic foods in their celebrations.  These foods may not be traditional but they increase the likelihood of other allergenic foods such as fish, shellfish, etc. to be the causative agent of an impending food allergy.  If someone has a serious food allergy, it is advisable for that person to bring their own food.

In addition to food allergies, one always is exposed to the typical environmental allergens such as dust mites, pets, molds, and to a lesser extent pollens.  By Thanksgiving, the pollen count in most places in the U.S. is low or non-existent, except in the southern states.  It is the molds, dust mites, and pets that tend to bother individuals during the end of November in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  These allergens can cause the typical symptoms of hay fever (I.e., allergic rhinitis and/or allergic conjunctivitis) and/or asthma which may include runny nose, nasal congestion, post-nasal drip, sneezing, itchy nose, itchy throat, sinus headaches, itchy eyes, watery eyes, redness of the eyes, wheezing, coughing, chest tightness, and shortness of breath.  One must keep in mind that many of these symptoms may mimic the symptoms of the common cold or flu (i.e., influenza) which tend to become more prevalent during this time of the year.

Other irritants that can cause allergic-like symptoms at a Thanksgiving Day event may include perfumes, colognes, cigarette smoke, smoke from a fireplace or wood-burning oven, and cleaning fluids.  Unfamiliar soaps may cause contact dermatitis to individuals with eczema (i.e., atopic dermatitis) and sensitive skin.

Thanksgiving is a festive time and loved by almost everyone.  It is a time to congregate with family and friends and an excuse to eat too much!  Given the positives about the Thanksgiving holiday, it is crucial to remember that there can be potentially serious complications from this seemly innocuous occasion.  With this in mind, have a very happy Thanksgiving!

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating allergies, asthma, sinus conditions, and immunological disorders for more than 50 years.  Black & Kletz Allergy has 3 convenient locations in the Washington, DC metro area with offices 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 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.  Please call us today to make an appointment at the office of your choice.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy specialists at Black & Kletz Allergy pride themselves in delivering the highest quality allergy care in the Washington, DC metropolitan area in conjunction with providing excellent customer service in a friendly and affable environment.

Allergic to Penicillin?

Adverse reactions to medications are very common.  Among the drugs associated with immediate hypersensitivity reactions (i.e., Type I allergy, IgE antibody-mediated allergy), penicillins are the most commonly observed.

Penicillin allergy is reported in approximately 7 to 10% of community populations and up to 20% of hospitalized patients.  What is amazing is that more than 90% of these patients do not actually have true penicillin allergy!

There are three common causes for this high rate of false positive penicillin allergy reports:

  1. Mislabeling of a side effect (e.g., gastrointestinal upset) as an “allergy”
  2. Coincidental event (e.g., headache or rash due to an underlying infection)
  3. Loss of true allergy sensitivity over time with avoidance of penicillins.

Penicillin allergy can be ruled out with the help of a standardized testing procedure which is routinely done in our office at Black & Kletz Allergy.  Skin testing was introduced as a diagnostic intervention for the evaluation and management of patients with a history of penicillin allergy in 1960’s.  This procedure is commonly performed with minimal risk.  Penicillin skin testing can be done safely in properly selected patients with suspected penicillin allergy and can even be performed in pregnant women with Streptococcal infections.

The procedure for testing involves three stages:

  1. Skin prick testing with a small amount of diluted penicillin “antigens” (commercially prepared testing reagents) with negative and positive controls.
  2. If the prick tests are negative after 20 minutes, a tiny quantity of the antigen in injected into the superficial layers of the skin (i.e., intradermal skin test).
  3. 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 three stages without any adverse effects, the patient may receive penicillins if needed, without increased risk of immediate allergic reactions.  The negative predictive value of penicillin allergy testing is more than 99%.

Penicillin allergy testing should be performed in a healthcare setting only by clinicians with the knowledge, training, and experience to select appropriate patients for this procedure, interpret test results, and manage a systemic allergic reaction should it occur.

Unverified penicillin allergy in hospitalized patients is associated with longer hospital stays and increased rates of serious drug-resistant infections.  The alternative antibiotics to penicillin can be associated with higher cost and/or greater risk for untoward side effects.

For this reason, the “Choosing Wisely” program of the American Board of Internal Medicine Foundation recommended in 2014 that clinicians not overuse non-penicillin antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation.  The National Quality Partners’ Antibiotic Stewardship Action Team recommends penicillin allergy skin testing as a component of a comprehensive antibiotic stewardship program.

Penicillin allergy testing is associated with an unrealized potential:  this procedure can accurately identify the approximately 9 of 10 patients who despite reporting a history of penicillin allergy can receive penicillins safely.

On the basis of current evidence, the American Academy of Allergy, Asthma and Immunology (AAAAI) believes that more frequent and routine performance of penicillin allergy testing will result in reduced costs of care, enhanced patient safety, and improved outcomes.

The board certified allergy doctors at Black & Kletz Allergy have been performing penicillin skin testing routinely for many years on both adults and children.  Black &Kletz Allergy has 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA which all offer on-site parking.  The Washington, DC and McLean, VA locations are Metro accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  Please call us to make an appointment or you can click Request an Appointment and we will reply within 24 hours by the next business day.  The allergists of Black & Kletz Allergy are eager to help you with your allergy, asthma, sinus, and immunology needs.  We are dedicated to providing excellent care and service to you as we have been doing in the Washington, DC metro area for more than 5 decades.

Influenza (Flu)

“Flu” season is almost here and it is time to get prepared for its onslaught.

Influenza is a highly contagious viral infection which is the cause of the “flu.”  It impacts people of all ages.  Though it can occur any time of the year, most cases are reported from October through March, with peaks between December and February of each year.  It affects between 5 to 20% of the U.S. population annually.  It accounts for thousands of lost school and work days.  It can be especially serious in the very young and the elderly.  Each year, more than 200,000 individuals are hospitalized and several thousand people die from the complications of influenza.

Symptoms:

Influenza usually presents initially as “cold-like” symptoms with runny nose, nasal congestion, itchy and/ or burning eyes, sore throat, and a dry cough.  Fever (usually 100°F – 102 degrees° F) is usually present and can be associated with chills.  Muscle aches (e.g., body aches) and fatigue are extremely common.  Joint pains, joint stiffness, gastrointestinal manifestations (e.g., diarrhea, nausea, vomiting) may also occur, but are not as common.

The symptoms usually lasts for approximately 7 to 10 days, but the malaise can continue for several weeks. Pneumonia is not an uncommon complication of the influenza virus and can substantially prolong the duration of illness.  Like other viral infections, influenza can also trigger acute flare-ups of asthma and chronic obstructive pulmonary disease (COPD) in susceptible individuals.

The influenza virus spreads from human to human via aerosols created by coughs and/or sneezes of infected individuals.  The incubation period ranges from 18 – 72 hours.  Shedding of the virus continues for 5 – 10 days in most individuals, however the duration of the shedding is longer in young children and immunocompromised persons.

Diagnosis:

There are rapid diagnostic tests that can directly detect influenza A or B virus-associated antigens or enzymes within 30 minutes by testing material obtained from throat swabs or nasal swabs.  Due to the cost, availability, and sensitivity of these tests, however, most physicians diagnose influenza based on clinical criteria alone.

Treatment:

Most patients with influenza benefit from rest and increased fluid intake and generally recover in a few days, though the fatigue may persist for weeks.  Antiviral medications can reduce the duration and severity of illness.  To be effective, these drugs must be started within 40 hours of the onset of symptoms.  There are two common antiviral medications used in the treatment and prevention of influenza A and B.  The first medication is oseltamivir (i.e., Tamiflu) which is taken orally 75 mg. twice a day for 5 days for individuals over the age of 12.  If using oseltamivir for prophylaxis for individuals 5 years of age and over, the dose is 10 mg. once a day for 10 days, but can be used in adults and adolescents (13 years of age and older) for up to 6 weeks for a community outbreak.  Smaller doses are given to children between the ages of 1 and 12.  The second medication is called zanamivir (Relenza) and is taken by inhalation using a Diskhaler (i.e., a device similar to an asthma inhaler) 10 mg. twice a day for 5 days for individuals 7 years of age and over.  If using zanamivir for prophylaxis for individuals 5 years of age and over, the dose is 10 mg. once a day for 10 days, but can be used in adults and adolescents for up to 28 days for a community outbreak.  Zanamivir should not be used by anyone who has respiratory problems such as asthma or other lung diseases.

Prevention:

Avoiding exposure to infected individuals and maximizing personal hygiene (e.g., frequent hand-washing with soap and water, not touching one’s nose and eyes) are the first line of defense in preventing the spread of the influenza virus.

Each year in U.S., vaccines that contain antigens from the strains most likely to cause infection during the winter flu season are produced.  These vaccines become effective 10 – 14 days after administration. It is recommended that all persons 6 months of age and above receive a routine annual influenza vaccination.

Only injectable vaccines are recommended for use during the 2017 – 2018 season.  The live nasal spray vaccine (e.g., FluMist) is not recommended due to concerns about its effectiveness against the H1N1 strains of the viruses.  A number of inactivated as well as recombinant vaccines are available for this season. Trivalent vaccines are designed to protect against three different influenza viruses (2 influenza A viruses and 1 influenza B virus). Quadrivalent vaccines protect against the same three viruses as the trivalent vaccine plus an additional influenza B virus.

In 2016, only about 50% if children ages 6 months to 17 years of age received the vaccine.  In adults 65 years of age and above, approximately 66% received the vaccine.  In individuals from ages 18 through 64, the percentage of people vaccinated for influenza was less than the two cohorts mentioned above.  Needless to say, there is great room for improvement in vaccinating the population against such a potentially virulent illness.

Special Populations:

Pregnant women can receive any licensed inactivated or recombinant trivalent or quadrivalent vaccine.  It is always advisable to check with your Obstetrician/Gynecologist physician and get his or her approval before receiving a flu vaccination.

Children between 6 months and 8 years of age who have never been vaccinated will require two doses of influenza vaccine administered at least 4 weeks apart.  If a child received two or more doses before July 1, 2017, only one dose of 2017 – 2018 flu vaccine is recommended.

As per the Centers of Disease Control and Prevention (CDC), children and adults with a history of severe allergic reaction to egg (i.e., any symptom other than hives) should receive the influenza vaccine in a medical setting under the supervision of a healthcare provider who is able to recognize and manage severe allergic conditions.  A previous severe allergic reaction to the flu vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to future receipt of the vaccine.

The board certified allergy doctors at Black and Kletz Allergy have 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We diagnose and treat both adult and pediatric patients.  The allergists at Black & Kletz Allergy are extremely knowledgeable about vaccinations as we specialize in immunological conditions. In addition, we also specialize in allergies (environmental, foods, insect stings, medications), asthma, sinus problems, eczema, generalized itching (pruritus), hives (urticaria), swelling episodes (angioedema), and eosinophilic disorders (e.g., eosinophilic esophagitis).  Each one of our offices offers on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle service that runs between our McLean, VA office and the Spring Hill metro station on the silver line.

If you would like to make an appointment to see one of our board certified allergists, please call us today.  Alternatively, you may click Request an Appointment and we will respond to your inquiry within 24 hours by the next business day.  Black & Kletz Allergy has been serving the Washington, DC and Northern Virginia metro area for more than 50 years and we look forward to helping you with you allergy, asthma, and immunologic needs.

Allergies and Halloween

Halloween is just around the corner and most individuals do not think of allergies when thinking of Halloween.  They more aptly think of costumes, trick-or-treating, candy, bobbing for apples, skeletons and skulls, and Halloween parties.  It is a festive time of the year and both adults and children enjoy the holiday.  Even though adults enjoy the event, it is the children that really become excited!

You may have never pondered about the connection between Halloween and allergies and you would not be alone.  Unfortunately, approximately 8% of all children in the U.S. have some type of food allergy.  These kids and their families are generally the only ones who connect this cheerful holiday with food allergies.  There is a good reason for this as food allergies can be very serious and in some cases fatal.  Almost 40% of children with food allergies have had a severe reaction to a food.  About 30% of children with food allergies have multiple food allergies.  According to Centers for Disease Control and Prevention (CDC), food allergies in children have increased by 50% between the years 1997 and 2011.  Peanut is the most common food allergy in children followed by milk.  The other 6 foods that are in the top 8 most allergic foods, (in addition to peanut and milk mentioned above) include shellfish, tree nuts, soy, wheat, eggs, and fish.  These 8 foods account for 90% of all food allergy reactions.  It is not surprising that Halloween candy often contains 6 of the 8 most common food allergens.  You guessed it, fish and shellfish are generally not a problem in Halloween candy, however, peanuts, tree nuts, milk products, soy, eggs, and/or wheat are found in a multitude of Halloween candy.  It is important to note that in some cases, miniaturized candies often given out during Halloween may contain different ingredients than their full-sized versions.  In addition, many miniaturized candies do not have labels which make it nearly impossible for the parents to deem the candy safe for their child.

What can be done to insure that a “food allergic” child can participate in Halloween and have as much fun as the next child?  Nothing is guaranteed, however, there is a program run by the Food Allergy Research and Education (FARE) organization called the “Teal Pumpkin Project”.  This FARE-sponsored international program has been around since 2014.   It began in Tennessee, however, as a local crusade in 2012 by the mother of a severely food allergic child.  She also created a food allergy support group called the Food Allergy Community of East Tennessee (FACET).

The Teal Pumpkin Project’s aim is to raise awareness of the severity of food allergies and show support to families who have a food allergic child.  This is accomplished by painting a pumpkin teal and placing it on one’s front porch to signify that non-food treats are available at that location on Halloween night.  The color teal was used because it represents food allergy awareness.  Typically, non-food treats may include toys, stickers, crayons, glow sticks, hair accessories, rings, bracelets, necklaces, coins, bookmarks, spider rings, vampire fangs, whistles, balls, finger puppets, etc.

Another important point is to clarify that the Teal Pumpkin Project is not exclusionary and it still promotes the option of giving out normal trick-or-treat candy to children without food allergies.  It recommends that the non-food items be kept in a different bowl than the traditional candy bowl.  FARE provides a “Teal Pumpkin Project Participation Map” on its website so that participating houses can be easily assessed by the parents of food allergic children.

The board certified allergists at Black & Kletz Allergy support the efforts of FARE’s Teal Pumpkin Project and hope that our patients will continue to expand this endeavor.  We have always had a link, on the upper portion of our website under the blue “Resources” tab, to the Food Allergy Research Education (FARE) organization.   If you or your child suffer from food allergies, food intolerances, or eosinophilic esophagitis, please call us to make an appointment.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas with on-site parking all 3 locations.  Our Washington, DC and McLean, VA locations are Metro accessible and we offer a free shuttle between our McLean, VA office and the Spring Hill metro station on the silver line.  We look forward to helping you with all your allergy, asthma, and immunology needs as we have been doing in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than a half century.

Food Protein-Induced Enterocolitis Syndrome

The most common type of food allergy is an “immediate hypersensitivity” reaction (i.e., Type I reaction), where the symptoms usually begin within a few minutes of exposure to the offending food.  These reactions are mediated by an antibody called IgE which interacts with the protein (i.e., antigen, allergen) in the food.  This interaction causes a release of chemicals which are responsible for the undesirable allergic symptoms.  The most common foods that cause these types of reactions are nuts and shellfish, though any food can theoretically trigger IgE.

Food Protein-Induced Enterocolitis Syndrome (FPIES), though not as common, can also cause serious and potentially life-threatening adverse effects.  IgE is not involved in these reactions, because FPIES is likely to be caused by a “cell-mediated hypersensitivity” reaction (i.e., Type IV reaction), where a specific type of white blood cell called a T-lymphocyte (i.e., T-cell) is thought to play a role.

Clinically, the most distinguishing feature of FPIES is that the symptoms typically begin a few hours after the ingestion of the food.  Though it can affect people at any age, it most commonly involves infants and young children.

50 to 60% of patients with FPIES have a family history of allergic disorders such as asthma, hay fever (i.e., allergic rhinitis) or eczema (i.e., atopic dermatitis) and approximately 20% have a family history of other food allergies.

Although any food can be a trigger for FPIES, the most common culprits are milk, soy, and grains.  Breast milk is not known to be a trigger and most infants develop symptoms when they are first introduced to formula or solid food.

Symptoms of FPIES (may include any or all of the following):

  1. Recurrent vomiting
  2. Diarrhea (occasionally mixed with blood)
  3. Dehydration
  4. Lethargy
  5. Failure to thrive
  6. Poor growth
  7. Shock-like symptoms – low blood pressure, pale and clammy skin; shallow fast breathing, weakness, dizziness, fainting, etc.

Note:  Unlike traditional IgE-mediated allergies, FPIES reactions do not manifest with itching, hives, swelling, coughing, and/or wheezing.

Diagnosis and Testing of FPIES

FPIES is occasionally mistaken for a bacterial or viral infection.  Although it is a type of allergy, prick skin tests and blood tests are not helpful in the detection of this condition.  The diagnosis primarily rests on a detailed history of ingestion of specific foods, nature and severity of the symptoms in conjunction with their temporal relationship with exposure, and a detailed physical examination.  Rarely oral food challenges under controlled conditions and clinical supervision are necessary to confirm the diagnosis.

Atopy patch testing is being studied for its effectiveness in diagnosing FPIES, as well as predicting if the problem food is no longer a trigger.  At this time, however, it is not considered a valid test to make the diagnosis.

Management of FPIES

The only option in the management of FPIES is strict avoidance of the triggering food(s).  A severe reaction might necessitate emergent intravenous fluids and rarely corticosteroid agents to control inflammation in the intestines. Occasionally, children may require hospitalization if the symptoms are very severe.

Epinephrine is usually not helpful in the treatment of FPIES and is not routinely prescribed, since this condition is a non-IgE-mediated reaction.

Most children with sensitivity to milk and soy can be well managed by switching to hypoallergenic formulas, such as a casein hydrolysate or amino acid based elemental formulas.  Many children sensitive to cereal grains can tolerate yellow fruits and vegetable based age-appropriate foods.  New foods are usually introduced very slowly, one food at a time, for an extended period of time per food.  In protracted cases, dietary advice from a certified nutritionist can be very helpful.

Prognosis of FPIES

In most instances, FPIES resolves spontaneously with time.  The affected children need to be closely monitored by a board certified allergist to determine if the condition has resolved.

With proper medical care and a personalized dietary plan to ensure proper nutrition, children with FPIES usually grow and develop normally.

We Can Help You

The board certified allergy doctors at Black & Kletz Allergy will promptly answer any questions you may have regarding FPIES or any related disorders.  Our allergists have been diagnosing and treating FPIES and other food allergies in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  We have 3 convenient locations in the DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  There is on-site parking at each location 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.  To schedule an appointment, please call us at any one of our 3 locations.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy is dedicated in providing the most up-to-date diagnostic and treatment modalities in the field of allergy, asthma, and immunology.

Recurrent Infections – Are They Due to Allergies?

Recurrent infections occur in many individuals in the U.S., as well as around the world.  In the U.S., malnutrition is not a common cause as it is in many undeveloped third-world countries.  Parasitic infections are also not very common in the U.S. unless an individual travels to a developing country, consumes uncooked meat/fish, drinks tainted water, or has an immune deficiency.  The most common types of infections found in the U.S. are numerous and include sinus infections, pneumonias, bronchial infections (i.e., bronchitis), skin infections (e.g., cellulitis, boils, abscesses), ear infections, throat infections, eye infections, gastrointestinal infections, urinary tract infections, and surgical site infections.  Nosocomial infections are a subset of infections specific to those infections that are acquired in a hospital setting.

The causative agents of most infections include bacteria, viruses, parasites, fungi, and prions.  These microbes or infectious agents can be transmitted in many ways such as person to person, mother to child, animal to person, and by food contamination.  Infections can be spread by direct contact, indirect contact, bug bites, and food contamination.

What about allergies?  Can they cause infections?  The answer is that having allergies predisposes an individual to the development of some types of infections.  The typical types of infections found more in allergic individuals may include sinus infections, ear infections, bronchitis, and pneumonia.  As a caveat to this, people with immune problems (i.e., immunodeficiencies) are more likely to develop infections.  In fact, most immunodeficiencies are found because the individual complains of recurrent infections.  People with immunodeficiencies can be stricken with infections from bacteria, viruses, fungi, and/or parasites.  These immune defects may involve B cells, T cells, NK cells (i.e., natural killer cells), phagocytic cells, and/or complement deficiencies.  The cells mentioned above are types of white blood cells in one’s body. Immunodeficiencies can be hereditary (i.e., genetic) or acquired (i.e., developed as a result of diseases, cancers, infections, malnutrition, or side effects of medications)

Some examples of hereditary immunodeficiencies include:

  1. B cell deficiencies – selective IgA deficiency, common variable immunodeficiency (CVID), X-linked agammaglobulinemia (i.e., Bruton’s agammaglobulinemia
  2. T cell deficiencies – DiGeorge syndrome, ataxia telangiectasia, Bloom’s syndrome, hyper IgE syndrome (Job’s syndrome), cartilage-hair hypoplasia, Wiskott Aldrich syndrome, X-linked lymphoproliferative syndromes, immunodeficiency-centromeric instability-facial anomalies syndrome (ICF syndrome), chromosome 22q11.2 deletion syndrome, candidiasis familial chronic mucocutaneous, dyskeratosis congenita, immunodysregulation, polyendocrinopathy and enteropathy X-linked (IPEX syndrome), hepatic venoocclusive disease with immunodeficiency, Schimke immunoosseous dysplasia
  3. NK cell deficiencies – classical NK cell deficiency (CNKD), functional NK cell deficiency (FNKD)
  4. Combined immunodeficiencies – severe combined immunodeficiency (SCID), X-linked hyper-IgM syndrome
  5. Phagocytic disorders – Chediak-Higashi syndrome, leukocyte adhesion deficiency, chronic granulomatous disease
  6. Complement system deficiencies – C1, C2, C3, C4, C5, C6, C7, C8, or C9 deficiency, properdin deficiency, mannose-binding lectin deficiency, factor B deficiency, factor D deficiency

Some examples of acquired immunodeficiencies include acquired immunodeficiency syndrome (AIDS), severe acute respiratory syndrome (SARS), cancers of the immune system (e.g., leukemia, multiple myeloma), and immune complex diseases (e.g., viral hepatitis).

In summary, many individuals suffer from recurrent infections and many can be attributed to allergy and/or immunology problems.  Allergic rhinitis, asthma, and immune disorders predispose individuals to the increase risk of various types of infections.  The allergists at Black & Kletz Allergy have been diagnosing and treating both adults and children with all types of infections for many decades in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We are board certified in both adult and pediatric allergy and immunology.  If you or someone you know suffers from recurrent infections (e.g., sinus, ears, lungs, skin), please call us to make an appointment at one of our 3 convenient offices.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of the offices have on-site parking.  The Washington, DC and McLean, VA offices are Metro accessible and the McLean, VA office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line.  You may also click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy has been a fixture in the greater Washington, DC and Northern Virginia community for over 50 years for our exceptional services for the diagnosis and treatment of allergic, asthmatic, and immunological conditions.

Eosinophilic Esophagitis

Definition:

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

Cause:

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

Mechanism:

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

Symptoms:

Children:

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

Adults:

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

Diagnosis:

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

Management:

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

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

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