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Exercise-Induced Hives, Angioedema, Anaphylaxis, and Asthma

In a small percentage of individuals, exercise can cause an array of allergic symptoms ranging from itching, to hives, to swelling episodes, to asthma symptoms, to a life-threatening anaphylactic reaction. The reactions can occur either during or after exercise. If you are experiencing any allergic symptom associated with exercise, you should see a board certified allergist.

In a subset of the population, exercise can induce generalized hives. This is called “exercise-induced urticaria.” The hives are itchy and can range in size from small red dots to large “welts” resembling mosquito bites. Other associated symptoms may include flushing, headache, and/or abdominal cramping. Individuals with this condition can develop hives when participating in exercise of any severity, but they tend to have more episodes when involved with moderate exercise such as jogging or running. In addition, aspirin and/or NSAID’s (i.e., ibuprofen, naproxen, diclofenac) and/or exercising in warm, humid, and/or cold climates, may increase the likelihood of developing hives in certain individuals. There is even a smaller population of individuals that have “food-dependent exercise-induced urticaria.” In this variant, individuals will get hives only if they eat a specific food and exercise within a certain amount of time (usually within 5 hours). This group of people can eat that specific food without problems and they can exercise without problems, but if they eat that food and exercise within 5 hours, they will get hives. The most commonly associated food linked with this condition is wheat. Other foods that have been most associated with food-dependent exercise-induced urticaria include crustaceans, buckwheat, celery, tomatoes, dairy products, chicken, octopuses, squid, and/or grapes, however, any food may cause this condition. There is an even a smaller population of individuals that develop hives after eating any food within 5 hours of exercising. Luckily, this condition is even rarer.

“Exercise-induced angioedema” is identical to exercise-induced urticaria except instead of developing hives, one develops swelling of a particular part of their body (usually of the face, lips, tongue, and/or eyes). This can be more serious if the swelling occurs in the throat which can lead to shortness of breath and complete constriction of the throat.

“Exercise-induced anaphylaxis” is a life-threatening condition that needs immediate attention. It essentially is the same condition as exercise-induced urticaria and exercise-induced angioedema, however, other systemic symptoms occur in addition to the itching, hives, flushing, and/or swelling. These systemic symptoms may include wheezing, shortness of breath, constriction of the throat, abdominal pain, diarrhea, vomiting, headache, anxiety, rapid or slow pulse rate, drop in blood pressure, and/or shock. Like exercise-induced urticaria and exercise-induced angioedema, exercise-induced anaphylaxis can be triggered by certain foods in select individuals. This condition also may be more likely to occur in individuals using aspirin and/or NSAID’s and/or exercising in warm, humid, and/or cold climates.

“Exercise-induced asthma” manifests itself with asthma symptoms such as shortness of breath, wheezing, chest tightness, and/or cough. It occurs much more frequently during exercise in allergic individuals and/or asthmatics compared to nonallergic and/or nonasthmatic individuals. However, it is important to note that even in these nonallergic and/or nonasthmatic people, exercise can still cause asthma symptoms. The asthma symptoms typically begin within 10-20 minutes after the start of exercise, but may not occur until 5-10 minutes after the conclusion of exercise. Exercising in the cold air is a common trigger. Air pollution, high pollen or mold levels and upper respiratory tract infections (e.g., sinus infections, “colds”, flu) also predispose a person to exercise-induced asthma. Warming up and cooling down exercises before and after exercise may decrease the likelihood and/or severity of the asthma symptoms.

Although each one of the above conditions is unique, they are all similar with respect to exercise as being the primary trigger. They all can be very serious and dangerous. At Black & Kletz Allergy, our board certified allergists have been treating both adults and children with exercise-induced conditions for over 50 years in the Washington, DC, Northern Virginia, and Maryland metropolitan area. We perform a comprehensive history and physical examination in conjunction with allergy skin and/or blood testing, pulmonary function testing, and/or other non-allergic blood testing to obtain an accurate diagnosis. We will discuss non-medication preventive measures with you as well as provide you with prescriptions for the necessary medications (e.g., EpiPen, antihistamines, asthma inhalers) to help prevent and/or treat your condition. Black & Kletz Allergy has office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA which all offer on-site parking. The Washington, DC and McLean, VA offices are also Metro accessible. If you have exercise-induced allergy or asthma symptoms, please call for an appointment or alternatively, you can click Request an Appointment and we will respond within 24 hours on the next business day.

Can Allergies Cause Flushing?

Flushing occurs when the blood vessels dilate and increase the blood supply to the skin. It is manifested as rapid reddening of the skin usually associated with a feeling of warmth. The episodes usually last for a few minutes at a time, but can last longer. If the blood vessels are dilated due to the activity of the nerves on them, flushing is also accompanied by sweating. Irritant chemicals and allergens may also directly act on the vessels producing “dry” flushing. Common triggers of flushing:

Eating:

  • Hot beverages and/or spicy food may cause flushing in normal people.
  • “Gustatory” flushing usually involves the face and can be associated with increased tear production, salivation, and nasal secretions, commonly seen after eating a hot pepper.
  • Injury to a parotid gland (a salivary gland) can cause flushing, warmth and sweating on one side of the face. This is called “Frey’s Syndrome” or “Auriculotemporal Nerve Syndrome.”
  • “Dumping syndrome”: Flushing of the face, sweating, diarrhea, increased heart rate, and fatigue may occur after eating a meal in people who have had certain types of surgeries on their stomachs.

Alcohol:

  • Certain fermented alcoholic beverages like beer and wine contain tyramine or histamine, which can cause flushing reactions.
  • Some Asians have a defective enzyme which leads to a build-up of acetaldehyde which causes flushing after consumption of alcohol. It is referred to as the “Asian Flush Syndrome.”
  • A few drugs like Antabuse (disulfiram), Flagyl (metronidazole) and cephalosporin antibiotics can also contribute to alcohol-induced flushing when used with alcohol.

Food additives:

  • “Chinese restaurant syndrome” refers to generalized flushing caused by MSG (monosodium glutamate) which is used a lot in Chinese restaurants in the U.S.
  • Sulfites, especially potassium metabisulfite, used as a preservative in beers, dried fruits, ciders, dairy products, wines, shrimp, and canned fruit and vegetable products, can induce flushing and wheezing. Asthmatics and people with aspirin sensitivity are more likely to react to sulfites.
  • Nitrites and nitrates in cured meats may cause flushing and headache in susceptible individuals.

Drugs:

  • Niacin (nicotinic acid) present in many multi-vitamin preparations in large doses can result in recurrent flushing. These episodes can be effectively blocked by aspirin or ibuprofen.
  • Medications used to lower blood pressure like vasodilators and calcium channel blockers, thyroid hormones and certain oral steroids can also produce flushing.

Neurologic causes:

  • Anxiety
  • Migraines
  • Spinal cord lesions above T6 level
  • Brain tumors
  • Parkinson’s disease

Menopause:

  • About 80% of postmenopausal woman have flushing associated with sweating.

Rosacea:

  • Chronic flushing from any cause can develop into rosacea. Individuals with rosacea typically have flushing of the cheeks and nose and occasionally on other areas of the face.

Scombroid fish poisoning:

  • Bacteria acting on inadequately refrigerated fish like mackerel, tuna, etc. convert the naturally occurring amino acid, histidine, in the fish to histamine which causes abdominal cramping, diarrhea, vomiting, hives, and flushing on consumption. The histamine can survive cooking so cooked and even canned tuna may also cause facial flushing.

Mastocytosis:

  • High levels of circulating histamine released from excessive numbers of mast cells in one’s body causes flushing, fainting, and shortness of breath.

Tumors:

  • Carcinoid tumors, (mostly of the stomach, small intestine, pancreas, ovaries, testis, and lung) can cause flushing in addition to wheezing, sweating, diarrhea, shortness of breath, palpitations of the heart, and abdominal cramping. If the primary tumor metastasizes to the liver, serotonin production is increased which causes severe flushing reactions.
  • Adrenal tumors like pheochromocytoma secrete catecholamines (epinephrine and norepinephrine) which induce flushing episodes.
  • Brain tumors

As the treatment depends on the cause, an attempt should be made to establish the precise underlying cause in all cases of recurrent flushing reactions with help of a detailed history, physical examination, and relevant blood and urine tests. The board certified allergists at Black & Kletz Allergy have had many decades of experience diagnosing patients who suffer from flushing. Once the cause is identified, the patient is told to avoid the offending trigger or they are referred to the appropriate specialist to treat the underlying condition. If you suffer from flushing, please do not hesitate to call us at Black & Kletz Allergy for an appointment. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA, all with on-site parking. Our Washington, DC and McLean, VA locations are also Metro accessible. Alternatively, you can Request an Appointment and we will respond within 24 hours of the next business day.

Mosquito Bite Allergy

Signs and Symptoms

Although mosquito bites are quite common among the general population, allergies to mosquito bites are luckily rather rare. Most individuals experience localized itching, swelling, and/or redness of the skin at the site of the bite. However, if someone is allergic to the mosquito, they may have more severe skin reactions which can include extremely large areas of swelling and redness, blistering, and/or bruising. In rare cases, some individuals may experience anaphylaxis (a severe life-threatening systemic reaction) after a mosquito bite. Such individuals experience symptoms which may include some or all of the following:

1. Throat closing sensation
2. Hives (Urticaria)
3. Generalized itching of the skin
4. Drop in blood pressure
5. Shortness of breath and/or wheezing
6. Dizziness, lightheadedness, and/or fainting
7. Abdominal cramping, nausea, vomiting, and/or diarrhea
8. Rapid and weak pulse
9. Feeling of warmth

Mosquito Facts

Mosquitoes are flying insects that tend to be more prevalent where there is standing water. They are more active early in the morning and early in the evening. Female mosquitoes lay their eggs in stagnant water. Only the female mosquito bites and feeds on human blood, as they need this blood in order to produce their eggs. Male mosquitoes feed on water and nectar. When a person is bitten, the mosquito injects its saliva into the skin which contains proteins that prevent the human blood from clotting. This allows the blood to be transferred to the mosquito’s mouth. The typical localized itching, swelling, and/or redness of the skin that results from the bite is not directly due to the bite itself, but rather caused by the body’s immune response to the proteins in the mosquito’s saliva. An “allergic reaction” to a mosquito bite is defined when there is a severe immune reaction against the salivary proteins of the mosquito, thus causing the more severe symptoms mentioned above.

Diseases Transmitted by Mosquitoes

In addition to causing allergies in selected individuals, mosquitoes are well known for transmitting many infectious diseases such as dengue fever, malaria, West Nile virus, filariasis (elephantiasis), yellow fever, chikungunya, Eastern equine encephalitis, Western equine encephalitis, Venezuelan equine encephalitis, Japanese encephalitis, St. Louis encephalitis, La Crosse encephalitis, Rift Valley fever, Ross River fever, and Zika fever.

Risk Factors

Mosquitoes are attracted to certain people more than others for a variety of reasons. They are more attracted to individuals with the following characteristics: Type O blood, males, obese or overweight people due to increased carbon dioxide (CO 2) levels, specific body odors that are present because of large numbers of certain bacteria, people wearing dark clothing, individuals that are exercising, and increased body heat.

Diagnosis, Prevention, and Treatment

The diagnosis of mosquito allergy can be done via a blood or skin test and is only done in individuals that have had severe reactions that can be ascertained after a thorough history from the patient. Prevention, however, is the key to treatment. One should avoid areas with standing water such as swamps or fresh water reservoirs. Wear light colored long sleeved clothing and hats. Consider wearing permethrin-treated clothing. Use citronella-scented candles when at outdoor events. Use a bed net if sleeping outdoors. Stay in screened in or air conditioned rooms. Apply insect repellent that preferably contains a 10-25% concentration of DEET (N,N-diethyl-3-methyl-benzamide or N,N- diethyl-meta-toluamide). One can alternatively use insect repellents containing either picaridin or oil of lemon eucalyptus.

Besides prevention, the treatment of mosquito bites is aimed at treating the symptoms of the bite. Since most mosquito bites cause only a local reaction, various topical medications can be used which can include calamine lotion, corticosteroid creams, anti-itch creams, and/or topical antihistamines. It may also be advantageous to apply ice or a cold pack to the site of the local reaction. Oral antihistamines may offer more relief in certain individuals. In the cases where anaphylaxis occurs, the individual should use a self-injectable epinephrine device (i.e., EpiPen, Auvi-Q, Adrenaclick), call 911, and go immediately to the closest emergency room. Fortunately, anaphylaxis is quite rare when it comes to mosquito bite allergies, however, it is a possibility and anyone who has symptoms of mosquito bite allergy should see a board certified allergist.

The board certified allergists at Black & Kletz Allergy have been serving the Washington, DC, Northern Virginia, and Maryland metropolitan area for over 5 decades and have office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA with on-site parking. The Washington, DC and McLean, VA office locations are also Metro accessible. Please call us for an appointment or alternatively, you can click Request an Appointment and we will get back in touch with you within 24 hours of the next business day. Black & Kletz Allergy prides itself in providing quality allergy care to both adults and children in a friendly professional environment.

A Spike in Allergy Symptoms in the Autumn?

As we enter into the ragweed season, some of us with seasonal allergies may experience a flare-up of symptoms.

Ragweed is one of the several weeds that pollinate in late Summer and the early Fall.  Seventeen different species of ragweed grow in the United States.  Common ragweed grows up to five feet tall.  It has hairy stems and light green leaves, up to four inches long.  Ragweed grows in fields, gardens, and along roadsides.  It is an annual plant, which means it only lives for one season.

Ragweed flowers are yellowish-green in color and small in size.  They grow in clusters of up to six inches long near the top of the plant.  Ragweed flowers produce large amounts of pollen. The pollen is transferred from one plant to another by the wind as well as insects.

Ragweed allergy occurs when an individual’s immune system produces a forceful response to a foreign substance (i.e., ragweed pollen) that is actually harmless in most circumstances.  As a result, the individual experiences hay fever (allergic rhinitis), allergic conjunctivitis, and/or asthmasymptoms (see below).

Certain cells of the body begin releasing antibodies to proteins in the ragweed pollen.  This results in the production of several chemicals (e.g., histamine) that cause these allergy symptoms.  Some individuals with ragweed allergy may also get local itching of the mouth and throat areas when they eat fresh melons, bananas, kiwi, cucumbers, zucchini, and/or avocados.  This condition is called oral allergy syndrome, which is also known as pollen-food allergy syndrome.

Each ragweed plant can release approximately one billion grains of ragweed pollen in one ragweed season.  The grains are so light that the wind easily carries them into the air where individuals inhale the grains.  The result is that these individuals may become sensitized and allergic to the ragweed pollen.  The pollen travels very far by the wind and pollen has been detected hundreds of miles away.  Some studies suggest that rising temperatures and carbon dioxide (CO2) levels are extending the ragweed season.  In Northern Virginia and Washington, DC, ragweed begins to pollinate in mid-August, peaks after the Labor Day weekend in September, and lasts until the end of October when the first frost ultimately kills the plant.

What are the Symptoms?

The allergic reaction to all plants that produce pollen is commonly known as hay fever (allergic rhinitis).  Symptoms can include itchy eyes, watery eyes, red eyes, puffy eyes, itchy nose, runny nose, stuffy nose, post-nasal drip, itchy throat, and sneezing.  In those with severe allergies, asthma symptoms (i.e., wheezing, shortness of breath, cough, chest tightness), sinusitis, headaches, fatigue, and impaired sleep may also occur.

What Methods of Prevention are Recommended?

A few simple suggestions can dramatically diminish one’s exposure to pollen:

  • It is preferable to stay inside when the pollen counts are at their highest.  In the Washington, DC area, this is in the mid-morning and the mid-afternoon.  One can track the pollen count in our area by clicking Today’s Pollen Count at the top of our website.
  • After being outdoors, change your clothes after returning indoors and take a shower to remove the pollen.  Do not hang clothes outdoors to dry, as the pollen will collect on them.  Use a clothes dryer instead.
  • Keep the windows closed in your car and home.   Turn on the air conditioner.  Make sure to change the air filters every 1-2 months.
  • Shower before bed to remove pollen, especially from your face and hair.
  • Use HEPA air filters in your home.

Diagnosing and Treating Ragweed Allergies:
When avoidance and prevention do not work, try over-the-counter medications.  If symptoms continue, or complications arise, it may be time to seek the advice of a physician.  The board certified allergists at Black & Kletz Allergy treat both adults and children with ragweed allergies and have done so for more than fifty years.  A thorough history and physical examination will be performed and allergy skin testing and/or allergy blood testing can be done in order to diagnose your condition.  Once a diagnosis of ragweed allergy is established, there are a multitude of medications available by prescription that can be tried in order to help alleviate your symptoms.  These medications come in the form of pills, capsules, syrups, powders, nasal sprays, eye drops, and inhalers.  Allergy shots (allergy immunotherapy, allergy injections) are an extremely effective means to treat not only ragweed allergy, but allergies (i.e., allergic rhinitis, allergic conjunctivitis, allergic asthma) in general.  They work in approximately 80-85% of individuals, but take about 4-6 months before they are effective for most individuals.  They have been around for over 100 years and can be given in children, adults, pregnant women, and the elderly with great success.

Black and Kletz Allergy has 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, Virginia (Tysons Corner, Virginia), and Manassas, Virginia.  The Washington, DC and McLean, VA offices are Metro accessible and all 3 locations offer on-site parking.  The allergists and staff at Black and Kletz Allergy will gladly answer any of your questions or concerns. We strive to offer individualized treatment plans in order to alleviate your unwanted allergy symptoms in a caring and professional setting.

Can Clogged Ears be Caused by Allergies?

The simple answer to this question is yes.

Eustachian tube dysfunction is a condition where the the eustachian tubes of the middle ear do not open and close the correct way.  The eustachian tubes are small tubes that go from the middle ear (the part of the ear behind the eardrum) to the back of the throat.  There is one eustachian tube for each ear.  The eustachian tubes are about 1 1/2 inches long and regulate the air pressure between the middle ear and the atmosphere outside the ear.  The eustachian tubes also serve the purpose of draining fluid and mucus from the middle ear.  Normally, the tubes are closed.  When there is an increase in atmospheric pressure ( e.g., high altitudes, deep water) people typically will intentionally swallow, yawn, or chew gum in order to force the eustachian tube open which will cause an equalization in pressure.  If someone is unable to equalize this pressure difference, one may experience ear pain, a clogged or blocked feeling of the ears, decreased hearing, ringing of the ears (tinnitus), a fullness of the ears, popping of the ears, and/or dizziness.

There are a variety of causes of eustachian tube dysfunction.  Swelling of the eustachian tubes can occur due to allergies (i.e., allergic rhinitis, hay fever), upper respiratory infections (URI’s), and sinus infections.  The swelling causes the tubes to stay closed, preventing them from opening with the normal everyday functions such as swallowing and yawning.  As a result, a pressure difference occurs between the middle ear and the outside atmospheric pressure causing the symptoms of eustachian tube dysfunction to develop.  One may complain of ears that are painful, blocked, full, popping, etc.  Fluid may also collect in the middle ear which can further increase one’s symptoms.  In addition, the fluid can get infected which will often lead to ear infections (otitis media).  Note that the length of the eustachian tubes is shorter, and thus more easily blocked, in children than in adults, predisposing them to a higher risk of ear infections; this is a reason to see a pediatric allergist here in McLean, Manassas or Washington, DC as soon as possible. /2015/08/04/can-clogged-ears-be-caused-by-allergies/ /2015/08/04/can-clogged-ears-be-caused-by-allergies/ /2015/08/04/can-clogged-ears-be-caused-by-allergies/ Cigarette smoking, enlarged adenoids, and obesity are other factors that can predispose and/or cause eustachian tube dysfunction.

As mentioned above, allergies play an important role in causing eustachian tube dysfunction.  Allergic rhinitis (hay fever) is a condition where there is inflammation and swelling in the nasal and sinus regions due to an allergen such as pollen, dust mites, molds, and animals.  It is the swelling component of this allergic condition which contributes to the symptoms of eustachian tube dysfunction.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating children and adults with “clogged ears” for over 50 years in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  Diagnosing and treating the underlying condition, which often is due to allergies, is the primary way to alleviate the “clogged ears.”  There are numerous allergy medications (i.e., decongestants, nasal corticosteroid sprays, antihistamines), as well as allergy immunotherapy (allergy shots) that can be utilized in order to treat and/or prevent “clogged ears.”  If you suffer from these symptoms or other allergy symptoms, please call any one of our 3 convenient office locations in the DC metro area.  We have offices in Washington, DC, McLean, VA, (Tyson’s Corner, VA), and Manassas, VA.  All 3 offices have on-site parking and the Washington, DC and McLean, VA locations are Metro accessible.  You can also click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy is dedicated to help you get relief from your allergy symptoms in a caring professional environment.

Summer Itch or Rash?

Outdoor activities in the summer can result in skin irritation and itching due to a variety of causes.

  1. PAPULAR URTICARIA:  It is an excessive skin reaction to insect bites.  Crops of itchy, red bumps usually less than a half-inch in diameter appear over the exposed areas of the body.  They sometimes progress into fluid filled blisters grouped together.  Scratching them may lead to crusting and/or infected pustules.  The lesions usually last for days to weeks.  Despite the name urticaria, they are not hives, which are raised wheals usually resolving in hours.  The most common insects causing these reactions are mosquitoes, gnats, fleas, etc.  Treatments like topical corticosteroids to lessen the inflammation and oral antihistamines to relieve the itching can be helpful. Application of insect repellants to exposed areas before outdoor activities may help prevent the problem.
  2. CONTACT DERMATITIS:  Skin exposure to the urushiol oil from the leaves of plants like poison ivy, poison oak, and poison sumac can cause severe redness, blistering, and burning sensation in sensitized individuals.  About 60-80% of individuals exposed to the urushiol oil become sensitized to it.  The condition usually begins 24-36 hours after exposure and can last a few weeks.  The lesions cannot be spread to other areas of the body through scratching or oozing of the blister fluid.  Because it can be a severe reaction, many patients will need corticosteroids by mouth for about a week to 10 days to control the condition.  Wearing long sleeves and pants, in addition to application of barrier creams before outdoor activities can be helpful in warding off the reaction in susceptible people.
  3. MILIARIA:  Prickly heat manifests as tiny red or pink spots over the face, neck, upper back, chest, etc.  This condition is caused by clogged up sweat pores which results in retention of excessive sweat which then leads to irritation and itching.  Friction caused by clothing can aggravate the problem.  This condition can be alleviated by using prickly heat powders, calamine lotion, staying in a cool environment, keeping the affected area clean and dry, and taking frequent cool and light baths or showers.  Occasionally, topical corticosteroids are necessary to provide relief.
  4. SUNBURN:  Prolonged exposure to the sun can cause red, irritated, burned, and/or itchy skin which can progress to blistering and open sores over the affected area.  Application of ice compresses and aloe gel can soothe the involved skin.  Avoiding excessive sun exposure, liberal use of sun block creams, and hydrating the skin with consumption of good quantities of clear liquids can be helpful.
  5. XEROSIS:  Xerosis is the medical term for abnormally dry skin.  Though excessive dryness is more common during the winter, prolonged exposure to air conditioned environments with little humidity can lead to dry and dehydrated skin.  Frequent bathing or showering and the use of strong soaps can remove essential skin oils causing the skin to be dry and itchy.  Applying a moisturizer thoroughly all over the skin immediately after a bath or shower will help in seal in the moisture and keep the water from evaporating, leaving the skin cool and moist.

The board certified allergists and trained staff at Black & Kletz Allergy in the Washington, DC, Northern Virginia, and Maryland metropolitan area can answer your questions and concerns regarding many skin conditions and will provide time tested and scientifically validated advice.  Our allergists specialize in both adult and pediatric patients.  We have 3 convenient office locations which all offer on-site parking.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  The Washington, DC and McLean, VA offices are also Metro accessible.  Please click Request an Appointment and we will answer you within 24 hours on the next business day.  For faster service, please call our office directly.  Black & Kletz Allergy prides itself in providing prompt quality care to the community in a caring professional setting.

Can a Cough Be Due to Allergies?

There are many cause of a cough.  Coughing is usually caused by a viral upper respiratory infection (URI), asthma, post-nasal drip, and/or gastroesophageal reflux disease (GERD).  There are however many other conditions which may cause a cough, some of which include other infectious types of upper respiratory infections (i.e., bacterial, fungal, parasitic), occult sinus infection, vocal cord dysfunction, cystic fibrosis, laryngopharyngeal reflux, pneumonia, bronchitis, bronchiectasis, pertussis (whooping cough), croup, foreign body (which can get stuck in one’s airways), pulmonary embolism, neurogenic cough, post-infectious cough, hypersensitivity pneumonitis, sarcoidosis, psychogenic cough (due to a habit or tic), Tourette’s Syndrome, aspiration, cigarette smoking, chronic obstructive pulmonary disease (COPD) (i.e., chronic bronchitis, and/or emphysema), interstitial lung disease, tumors, congestive heart failure, exposure to air pollutants, and the side effects of certain medications such as angiotensin-converting enzyme inhibitors [(i.e., lisinopril (Zestril, Prinivil), enalapril (Vasotec), ramipril (Altace), benazepril (Lotensin), captopril (Capoten), fosinopril (Monopril), quinapril (Accupril), trandolapril (Mavik), moexipril (Univasc), and perindopril (Aceon)].

So can allergies play a role in causing a cough?  Yes.  Since asthma is a leading cause of cough and about 80% of individuals with asthma also have allergies, one can see right away that allergies play a large role in causing a cough.  In addition, there is a sub-group of asthmatics who have a condition called cough-variant asthma where sufferers only cough as a result of their asthma.  They do not have the accompanying wheezing, shortness of breath or chest tightness that most other asthmatics experience.  As if this wasn’t bad enough, it is estimated that 75-80% of asthmatics have gastroesophageal reflux disease (GERD), which is also one of the most common causes of a cough.  Allergies also play a major role in predisposing a person to develop a sinus infection (sinusitis) which again often causes a cough.  Immunodeficiency disorders (which are diagnosed and treated by allergists/immunologists) such as hypogammaglobulinemia also predispose people with these disorders to acute sinus infections.  Hypersensitivity pneumonitis is a condition where there is an inflammation of the air sacs (alveoli) of the lungs caused by an allergic reaction to inhaled antigens such as dusts, molds, and chemicals.  Individuals with this condition commonly have certain hobbies and/or occupations that expose them to these antigens.  Once again, cough is a primary symptom of this disease.

In individuals with a persistent cough, many tests can be done in order to diagnose the reason behind the cough.  Some of these tests include blood work, chest X-rays, CT scans of the chest and/or sinuses, allergy testing, pulmonary function tests (PFT’s; breathing tests), rhinoscopy, upper endoscopy (with or without biopsy), esophageal manometry (assesses the function of the lower esophageal sphincter and esophagus), barium swallow, pH monitoring (measures the acidity in the stomach), and bronchoscopy (with or without lung biopsy).  In most cases, the workup usually does not require the last six tests listed above which are generally reserved for difficult cases.  After diagnosing the problem, there are a variety of medications that can be used to treat an individual’s cough.

The board certified allergists at Black & Kletz Allergy have been diagnosing the underlying conditions of coughs and treating individuals with coughs for more than 50 years in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We treat both adult and pediatric patients and have 3 convenient locations in the DC metro area.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA) and Manassas, VA, each with on-site parking.  The Washington, DC and McLean, VA offices are Metro accessible.  Black and Kletz Allergy is committed to providing excellent allergy, asthma, and immunology care to the greater Washington, DC and Northern Virginia community.

Allergic Fungal Sinusitis

Allergic Fungal Sinusitis (AFS) is a chronic inflammatory condition involving the nose and sinuses caused by an allergic sensitivity to environmental fungi.  It is usually seen in people with normal immune systems as opposed to invasive fungal infections which usually affect people with compromised immune systems caused by conditions which may include diabetes mellitus, certain cancers, HIV infection, and patients receiving chemotherapy or radiation treatment.  It is similar to a condition that affects the lung called Allergic Bronchopulmonary Aspergillosis (ABPA).

Many patients with AFS are atopic, meaning they have a tendency to develop allergic sensitization when exposed to common harmless substances like pollens, dust mites, cats, dogs, and certain foods.  About two-thirds of patients with AFS also have allergic rhinitis and up to half of them also have allergic asthma.  AFS is most commonly seen in young adults with an average age of 22 years.

CAUSE:

When an atopic person breathes in air containing the fungus, it triggers an allergic inflammation of the mucus lining inside the nostrils and sinuses resulting in swelling of the tissues.  This swelling leads to blockage of the sinus drainage pathways causing the mucus secretions (mucin) to accumulate within the sinus cavities.  This, in turn, creates an ideal environment for further reproduction of the fungus.  The sinuses are eventually filled with a viscous and tenacious fungal mucin which has the consistency and appearance of peanut butter.

SYMPTOMS:

  1. Nasal congestion
  2. Discolored copious nasal secretions
  3. Semi-solid nasal crusts
  4. Polyp formation in the nose and the sinuses
  5. Post-nasal drip
  6. Throat irritation
  7. Occasional headache or facial pressure
  8. Decreased sense of smell

In advanced stages, facial disfigurement and vision disturbances may also be encountered due to extension of the disease to the surrounding areas.

DIAGNOSIS:

  1. Total IgE antibody levels in the blood will be elevated several times the normal limits.
  2. Skin testing to various fungal organisms.
  3. CT scan of the sinuses can demonstrate accumulated fungal mucin in the sinus cavities.
  4. Mucin drained from the sinuses needs to be examined for specific histological characteristics under the microscope and cultured in the laboratory to identify the specific type of fungus.

TREATMENT:

  1. Fungal mucin in the sinuses needs to be drained out by endoscopic sinus surgery.
  2. Systemic and topical steroid medications to reduce the inflammatory changes and shrink the polyps.
  3. Environmental control to reduce the exposure to the fungi and molds.
  4. Systemic or topical antifungal medications may be used to reduce the amount of fungus.
  5. Allergy immunotherapy (allergy shots) with the antigens identified by skin testing to develop tolerance to the fungal allergens and to control the chronic inflammatory reactions.

A comprehensive management plan incorporating medical, surgical, and immunologic care remains the most likely means of providing long-term disease control for allergic fungal sinusitis (AFS).

The board certified allergists at Black & Kletz Allergy in the Washington, DC, Northern Virginia, and Maryland metropolitan area have been treating sinus disease for more than 5 decades.  We have expertise in recognizing and managing individuals with allergic fungal sinusitis.  Black & Kletz Allergy has 3 convenient locations in the Washington, DC area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have on-site parking at each location.  In addition, the Washington, DC and McLean, VA offices are accessible by the Metro.  If you suffer from any of the above symptoms, please contact one of our offices to make an appointment.  Alternatively, you can click Request an Appointment and we will contact you within 24 hours of the next business day.  We strive to serve the community in a professional, friendly, and caring manner.