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Allergies to Mold, Mildew, Yeast, and Fungus

It is quite common for individuals to be allergic to mold, particularly in the Washington, DC, Northern Virginia, and Maryland metropolitan area. Not only is the humidity elevated in this region, but Washington, DC was built on a swamp. In the Spring, it rains quite often contributing to an increase in moisture and thus mold. In the Summer, the metro area tends to be hot and humid which is ideal for mold growth. During the Fall, the leaves fall from the trees and get wet which is the perfect environment for the development and progression of mold. Even during the Winter mold can flourish particularly since mold lives both indoors and outdoors. In the home, molds tend to be more prevalent in bathrooms, kitchens, and basements, where moisture is more common. It is interesting to note that some molds can survive in very arid environments such as a desert. Any way you slice it, mold is year-round problem for residents and visitors of the Washington, DC metropolitan area.

Mold is a fungus that grows in the form of multicellular filaments that are known as hyphae.  There are over 400,000 types of molds. Mildew is also a fungus that closely resembles mold. Mold typically looks fuzzy in appearance while mildew characteristically is flat in appearance. The color of mold tends to be black, blue, green, or red whereas the color of mildew tends to be white, brown, or gray. Mold and mildew produce undesirable odors that many people find offensive or downright problematic as they can cause “sicknesses” to those exposed. Fungi that grow in a single-celled environment are called yeasts.  Regardless of their characteristics, mold, mildew, and yeast can all play havoc to individuals who are either sensitive or allergic to them. Regarding allergies to mold, mildew, yeast, and fungi, an allergy to any one of them is generally grouped into one category as “allergy to mold,” as opposed to an allergy to mildew, an allergy to yeast, or an allergy to fungi.

Molds produce tiny microscopic which are their reproductive structures. The diameter of a mold spore generally varies between 3 to 45 microns which is less than half the width of a typical human hair. The mold spores begin are released into the air and since they are tiny in size, they are able to float in the air, where they can be easily inhaled by sensitive individuals. Mold spores flourish in any milieu with a constant source of moisture. As mold grows, the tiny spores begin to undergo chemical reactions that allow them to consume nutrients and further replicate.  These chemical reactions produce fumes which are released into the atmosphere. These fumes are responsible for the unpleasant musty odor that everyone is familiar with.

Mold generally can cause annoying symptoms in 4 different ways. The first is from a true allergy to the mold. The most common type of symptoms from mold allergy are the kinds of symptoms one may experience from other environmental allergens such as dust mites, pollens, pets, or cockroaches. These allergic rhinitis (i.e., hay fever) and allergic conjunctivitis (i.e., eye allergies) symptoms may include sneezing, runny nose, post-nasal drip, nasal congestion, itchy throat, sore throat, sinus headaches, snoring, itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes. Severely affected individuals as well as asthmatics may also develop asthma symptoms or an exacerbation of their asthma which may include wheezing, chest tightness, coughing, and/or shortness of breath. The diagnosis of mold allergy necessitates a comprehensive history and physical examination in conjunction with allergy testing (skin tests and/or blood tests). The treatment of mold allergy always begins with prevention. Avoiding mold is always preferable if at all possible. Some of the ways to help reduce mold exposure may include decreasing outdoor activities when mold counts are high, repairing any leaks, lowering the humidity, using a dehumidifier, using air conditioner with a HEPA filter, removing carpets in locations where they are in danger of becoming wet, and masking when engaging in yardwork. The treatment of mold allergy consists of allergy medications (e.g., antihistamines, decongestants, nasal corticosteroids, nasal antihistamines, leukotriene antagonists, eye drops, asthma inhalers) to help relieve 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 receive them. Allergy injections have been given in the U.S. for more than 100 years as they get more to the root of the underlying problem by allowing a patient to develop protective antibodies against mold as well as other allergens such as dust mites, pollens, pets, and/or cockroach.

An unusual allergy to mold exists in roughly 1-2% of individuals with asthma. These individuals have an allergic reaction to a specific type of mold known as Aspergillus fumigatus.  Similarly, between 2-15% of children with cystic fibrosis have the same reaction to this same mold. Asthmatic and cystic fibrosis patients that react to this mold have a condition known as allergic bronchopulmonary aspergillosis (ABPA). The symptoms of ABPA are similar to that of asthma except they may also cough up sputum with brownish flecks and they may also have a mild low-grade fever. Such patients should be worked up for ABPA via X-rays/CT scans, pulmonary function tests, sputum cultures, blood tests, and allergy skin tests. The treatment of ABPA usually involves the use of medications to treat asthma with the possible addition of oral corticosteroids and/or antifungal medications.

The second way mold can affect an individual is from a non-allergic irritant reaction. Molds can release substances known as volatile organic compounds (VOC’s) which can irritate skin and mucus membranes inside the mouth, nose, and eyes resulting in burning sensation of the skin, itchy throat, runny nose, itchy eyes, watery eyes, and/or cough. Avoidance is the best way to prevent irritant reactions. Using air filters may also be of help.

The third manner in which a mold can cause bothersome symptoms is via a toxic reaction usually by way of inhaled or ingested toxic compounds called mycotoxins, which are produced by the mold. The molds that produce mycotoxins can pose serious health risks to humans and animals.  Some studies claim that the exposure to high levels of mycotoxins can result in neurological complications and prolonged exposure may be particularly harmful. The research on the health effects of these types of molds is somewhat controversial and it 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 remediation by a professional mold remediation service is the best way to remedy this situation.

The fourth method in which a mold can cause unwanted symptoms is by causing an infection. This results from the growth of a pathogenic mold within the body. The most common way that molds/fungi cause infections is through the skin. It should be noted that different types of molds/fungi can cause infections in other organ systems which may lead to gastrointestinal, respiratory, and/or neurological problems. Antifungal medications and occasionally other medications are used in order to eliminate the fungal infection.

The board certified allergy doctors at Black & Kletz Allergy will promptly respond to any questions regarding mold allergy or any other allergic or immunologic disorders. We have been treating mold allergies for more than 50 years and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have been serving the Washington, DC, Northern Virginia, and Maryland metropolitan area for a long time and treat both pediatric and adult patients. All 3 offices at Black & Kletz Allergy 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 are concerned that you may have a mold allergy or any other allergy, asthma, sinus, skin, or immunology problem(s), please call us to schedule an appointment. You may also click Request an Appointment and we will answer within 24 hours by the next business day. At Black & Kletz Allergy, we strive to improve the quality of life in allergic and asthmatic individuals in a professional and compassionate environment.

Nasal Polyps Update

Nasal polyps (i.e., nasal polyposis) are soft, benign growths that develop from the lining of the sinuses and nasal cavity. Approximately 4-5% of the general population has nasal polyps. They look like glistening moist grapes and are typically in the shape of teardrops. These new growths result from chronic inflammation of the tissues inside the nasal and sinus cavities. When the nasal polyps grow large enough, they may obstruct the nasal passages which will block the flow of air through the nose. The mechanical obstruction may also block the passage of secretions from the sinuses into the nose which may result in the predisposition of individuals to develop recurrent or chronic sinus infections.

CAUSES:
Any condition which ends in chronic inflammation inside the sinuses and nose may lead to the formation of nasal polyps.   Some of these conditions may include:
1. Allergic sensitivity to indoor or outdoor environmental allergens [allergic rhinitis (i.e., hay fever)] mediated by an the IgE antibody and elevated levels of interleukin 5 (IL-5) cytokine.
2. Chronic sinus infections from bacteria such as Staphylococci as seen in chronic rhinosinusitis with nasal polyposis (CRSwNP).
3. Allergic response to fungal organisms in the inhaled air which is called allergic fungal rhinosinusitis (AFRS).
4. Systemic inflammatory disorders such as aspirin exacerbated respiratory disease (AERD) and cystic fibrosis (CF). Aspirin exacerbated respiratory disease is also called Samter’s triad because it consists of 3 features: asthma, nasal polys that re-occur, and an intolerance to aspirin and NSAID’s (nonsteroidal anti-inflammatory drugs). Between 6% and 48% of individuals with cystic fibrosis develop nasal polyps, so cystic fibrosis should be entertained in anyone who presents with nasal polyps.
5. Eosinophil (i.e., a type of white blood cell) disorders such as eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome.
6. Chronic irritation from smoke, strong odors, and pollutants in the air.
7. Immunodeficiencies such as common variable immunodeficiency, selective IgA deficiency, and primary ciliary dyskinesia

SYMPTOMS:
The symptoms of nasal polyps usually include nasal congestion and a runny nose in the early stages. As time goes on, nasal congestion resulting in a difficulty in breathing through the nostril(s) may occur. The nasal congestion usually worsens as the size of the polyp increases. Other symptoms of nasal polyps may include post-nasal drip, facial pain, headache, decreased or loss of taste (i.e., ageusia) and/or smell (i.e., anosmia), and snoring.

DIAGNOSIS:
The diagnosis of nasal polyps is generally made by examining the nasal cavity with a light source. The presence of nasal polyps will be revealed by shiny, mobile, smooth, gray, and semi-translucent masses. These Inflammatory polyps are usually present in both nostrils. It is important to note that some neoplastic polyps may only be present on one side (i.e., in one nostril). Rhinoscopy is often utilized to visualize the nasal cavity. Imaging of the sinuses with a CT scan may be needed in order to estimate the extent of the polyposis and to plan for surgical removal, if indicated. Allergy testing (e.g., skin testing, blood testing) is often performed to check for environmental allergies. A sweat chloride test may also be performed particularly in children in order to rule out cystic fibrosis.

COMPLICATIONS:
Some complications may arise from having nasal polyps. The problems may include nose bloods (i.e., epistaxis), recurrent or chronic sinusitis, asthma exacerbations, obstructive sleep apnea/snoring, and rarely double vision (i.e., diplopia).

TREATMENT:
1. Intranasal corticosteroid sprays [e.g., Flonase (fluticasone), Nasonex (mometasone), Nasacort (i.e., triamcinolone), Rhinocort (i.e., budesonide), Nasarel (i.e., flunisolide), Xhance (fluticasone)] on a daily basis.
2. Short courses of oral corticosteroids can shrink nasal polyps.
3. Saline irrigation: High-volume, low-pressure nasal saline irrigations are safe and non-expensive. Irrigation increases the clearance of antigens, biofilms, and inflammatory mediators.
4. Topical antihistamine nasal sprays [e.g. olopatadine (Patanase), azelastine (Astelin)]
5. Irrigation or nebulization with anti-inflammatory agents such as budesonide or mometasone in cases of CRSwNP.
6. Allergy testing and allergy immunotherapy (i.e., allergy shots, allergy desensitization, allergy hyposensitization) with relevant inhaled environmental allergens is effective in the treatment of allergic rhinitis, allergic conjunctivitis (i.e., eye allergies), and asthma in 80-85% of the patients that take them.
7. Deposition of corticosteroid medications higher into the nasal cavity by exhalation devices such as Xhance (i.e., fluticasone).
8. Biologic medications such as dupilumab (i.e., Dupixent) given by injections under the skin every 2 weeks, omalizumab (i.e., Xolair) given under the skin every 4 weeks, or mepolizumab (i.e., Nucala) given under the skin every 4 weeks.
9. Aspirin desensitization for AERD.
10. Functional endoscopic sinus surgery (FESS) and excision of the nasal polyps, restoring the patency of the nasal cavity.
11. Polyps have a tendency to recur after surgery and/or aggressive allergy treatments and intranasal corticosteroids can delay or prevent the recurrence.
12. Placing tiny, corticosteroid-coated implants (e.g., Sinuva) in the sinuses.

PREVENTION:
The aggressive management of predisposing conditions such as allergic rhinitis, controlling one’s environment [i.e., reducing one’s exposure to offending allergens such as dust mites, molds, pollens, cats, dogs, and cockroaches, allergy medications, and allergy immunotherapy (i.e., allergy shots, allergy injections, allergy immunotherapy, allergy hyposensitization) may all work together to inhibit polyp formation.  In addition, avoiding exposure to strong odors, chemicals, and smoke is important in order to diminish nasal irritation and excessive tissue growth.

Individuals with established chronic sinusitis may require antibiotics, nasal or sinus irrigations, and/or sinus surgery.  Patients with a history of aspirin sensitivity should do better after desensitization to aspirin in terms of improved asthma control, as well as a reduction in the recurrence of nasal polyps.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating both children and adults in the Washington, DC, nNorthern VA, and Maryland metropolitan area for over 50 years. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. There is on-site parking at all of the offices. The Washington, DC and McLean, VA office locations are Metro accessible and there is a free shuttle that runs between our McLean office and the Spring Hill metro station on the silver line. The allergy doctors at Black & Kletz Allergy specialize in all types of allergic conditions including nasal polyps, hay fever, asthma, sinus disease, hives (i.e., urticaria), eczema (i.e., atopic dermatitis, swelling problems (i.e., angioedema), food and medication allergies, and immunological disorders. If you would like to schedule an appointment, please call us or alternatively you can click Request an Appointment and we will respond back to you within 24 hours on the next business day. We look forward to providing you with comprehensive state-of the-art allergy care in a friendly and professional environment.

Fall Allergies

As we approach the end of Summer in the coming month, many individuals will begin to experience an increase of their allergy symptoms. In the world of allergies, these symptoms are considered Fall allergies. Typically in the Washington, DC, Northern Virginia, and Maryland metropolitan area, ragweed begins to pollinate in mid-August. The release of ragweed pollen into the air can be dreadful for many ragweed-allergic individuals. As the ragweed pollen count climbs through the rest of August and throughout most of September, the allergic rhinitis (i.e., hay fever), allergic conjunctivitis (i.e., eye allergies), and/or asthma symptoms of patients with ragweed allergy usually increase proportionally. The end of ragweed season coincides with the first frost which is usually in late October in the Washington, DC metro area. Approximately 10% of the population in the U.S. has a ragweed allergy. There are 17 species of ragweed in North America. Each ragweed plant produces about 1 billion pollen grains per season. The only state in the U.S. without ragweed is Alaska. Ragweed is more common in the Midwest and eastern U.S. Warm temperatures and increased humidity are factors that augment the release of ragweed pollen.

The classic symptoms that people with ragweed allergy experience may include runny nose, nasal congestion, post-nasal drip, sneezing, itchy nose, itchy throat, sinus congestion, sinus pain, headaches, snoring, itchy eyes, watery eyes, puffy eyes, redness of the eyes, chest tightness, coughing, wheezing, and/or shortness of breath. Ragweed may also increase the likelihood of sinus infections (i.e., sinusitis) in some susceptible individuals.

An itchy mouth, throat and/or lips can occur in some ragweed-allergic individuals after eating certain ragweed-associated foods. The foods that may be associated with ragweed pollen allergy include banana, melon (e.g., watermelon, cantaloupe, honeydew), white potato, chamomile tea, cucumber, zucchini, artichoke, sunflower seeds, and dandelion. In general, no other allergy symptoms beyond an itchy mouth, throat, and/or lips occur. This condition is called oral allergy syndrome or pollen-food allergy syndrome. The syndrome in general is caused by allergens in foods that are derived from plants. Furthermore, these foods are usually raw or uncooked fruits, vegetables, and nuts. Only foods that come from plants can cause the syndrome. Extra caution needs to be taken into account where nuts cause symptoms because many individuals can have nut allergies that are not associated with plants which may be life-threatening. Ironically, when the fruit or vegetable is cooked or canned, the protein is denatured and destroyed which usually prevents the allergic reaction from occurring. In most instances, individuals can tolerate cooked and/or canned fruits and vegetables.

In addition to ragweed as a cause of Fall allergies, molds, dust mites, pet dander, and cockroaches are also major sources of Fall allergies. Molds are perennial in nature and occur naturally in both indoor and outdoor settings. Washington, DC is notorious for its mold content as it was built on a swamp. In addition, the amount of mold tends to be worse in the Washington, DC metro area in the Spring with all of the rain and in the Fall with the increased amount leaf mold from all of the moldy wet leaves on the ground. Avoiding damp places, not raking leaves, and keeping the humidity below 50% may help in minimizing one’s exposure to molds. Dust mites are indoor allergens and are a problem for allergy sufferers year-round. Dust mites tend to live in bedding (i.e., mattresses, pillows, box springs), carpeting, and upholstered furniture. Covering one’s pillows, mattresses, and box springs with allergy-proof encasings and limiting stuffed animals and dust gathering objects has shown to help minimize one’s exposure to dust. Pets (e.g., cats, dogs, rabbits) can obviously cause allergy symptoms in pet-allergic individuals. Avoiding contact with pets, keeping a pet out of the bedroom, and washing the pet can all help reduce one’s exposure to pets. Cockroaches are potent allergens that cause perennial symptoms due to their ubiquitous nature. They are notable in the field of allergy and immunology for being a leading aggravating factor of childhood asthma in inner city populations. Extermination of cockroaches by professional exterminators can help reduce one’s exposure to cockroaches.

The board certified allergy specialists at Black & Kletz Allergy have been diagnosing and treating allergies, asthma, sinus conditions, and immunological disorders for more than 5 decades. 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 doctors at Black & Kletz Allergy pride themselves in delivering the highest quality allergy care in the Washington, DC metropolitan area in conjunction with providing an excellent patient experience in a friendly and pleasant environment.

Food Allergy vs. Intolerance vs. Sensitivity

There are different mechanisms that play a role in the causation of adverse and undesirable effects triggered by the consumption of food. In the world of food allergies, It is important to distinguish between these mechanisms in order to arrive at an accurate diagnosis. Allergy, intolerance, and sensitivity to foods require different diagnostic approaches including a careful history and skin or blood testing in order to diagnose the condition. The management of these conditions also varies based on the underlying mechanisms.

An allergy to a food traditionally means that there is an immunologic reaction to proteins in that food. This reaction is usually mediated by specific antibodies (IgE antibodies or immunoglobulin E antibodies) to these proteins. These antibodies react with the protein antigens in the food. These reactions result in a release of chemical mediators such as histamine and tryptase from mast cells and basophils into the tissues and bloodstream.

These chemical mediators (e.g., histamine, tryptase) also have adverse effects on the blood vessels, heart, lungs, and other vital organs. The result of this release of chemical mediators could vary in severity from mild itching of the skin to a severe life threatening reaction such as anaphylaxis. Ingestion of even small amounts of food can trigger such reactions, which usually begin within minutes of exposure.

The most important element in diagnosing food allergies is taking a careful and comprehensive history from the patient. It is important for the board certified allergist to focus on the specific food ingested (including the list of ingredients in prepackaged foods) as well as the timeline of the onset and progression of the symptoms. The history is complemented by the detection of specific IgE antibodies to the food(s) in question by way of skin testing and/or blood testing. These specific IgE allergy tests should be limited to only the foods that could have triggered the reaction suggested by the history.

Treatment of food allergies traditionally has been focused on the identification and subsequent strict avoidance of the offending food(s). Patients are also prescribed an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) to be used in case of a systemic reaction following an inadvertent exposure to the food. However, more recently, a desensitization procedure to foods such as peanuts by way of oral immunotherapy has become available.

As opposed to an allergy, an intolerance to a food is not mediated by an immunologic process. Instead, the process primarily involves the gastrointestinal system rather than the immune system. An insufficiency of certain enzymes usually found in the gastrointestinal system may hinder the proper digestive process and result primarily in gastrointestinal symptoms. A common example is lactose intolerance, where an enzyme called lactase is deficient. Lactose is a sugar found in dairy products. The enzyme lactase breaks down the lactose in normal individuals. In patients with lactose deficiency (i.e., lactose intolerance) the undigested lactose becomes fermented in the intestines which causes uncomfortable gastrointestinal symptoms such as nausea, abdominal discomfort, abdominal bloating, flatulence, and/or diarrhea after the consumption of dairy products. The symptoms are usually dose-dependent, meaning that the symptoms are usually worse the more you eat/drink.

Breath hydrogen tests are sometimes helpful in confirming the diagnosis of lactose intolerance. The treatment involves either avoidance of the foods one is intolerant to or supplementation with the oral enzymes (e.g., lactase enzyme) along with these foods in order to help in their digestion.

A sensitivity to a food is a poorly understood phenomenon and may involve non-specific inflammation of the gut. The symptoms are widely variable and may include abdominal pain, nausea, diarrhea, fatigue, joint pain, brain fog, and/or vague constitutional symptoms. The symptoms can begin hours or days after the food exposure and can be chronic in nature. The symptoms may be mediated by an immunologic processes but IgE antibodies are not usually involved. Some researchers speculate that IgG antibodies specific to foods may be involved, although it has not been scientifically proven. Interestingly, some IgG antibodies to certain foods can protect an individual from sensitivity and in fact, their levels are shown to rise after desensitization to those foods.

As the value of IgG antibodies in diagnosing food sensitivities has never been conclusively established, tests to measure IgG levels in blood against foods should not be ordered or obtained.

Of note, some physicians will lump food intolerance and food sensitivity into the same category.

Another caveat in the diagnosis of food allergies is that even elevated IgE antibody levels against specific foods do not always correlate with reactions after the consumption of these foods. False positives and false negatives can and do occur. Hence, the results should always be interpreted in the context of clinical reactions after exposure.

In view of the above mentioned nuances, ordering “broad panels” of specific IgE to various foods without correlating it to the patient’s history is not helpful in the diagnosis of food allergies. IgE levels should be obtained only to those specific foods that the patient could have reacted to, which should be based on the patient’s history. It is important to correlate the timeline of symptom onset as well as the progression of the symptoms after the exposure to the food.

The board certified allergists at Black & Kletz Allergy have 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area and are very experienced in the diagnosis and treatment of food allergy, food intolerance, and food sensitivity. Black & Kletz Allergy diagnose and treat both children and adults and have 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, 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. Please call our office to make an appointment or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been serving the Washington, DC metropolitan area for more than 5 decades and we pride ourselves in providing exceptional allergy, asthma, and immunological care in a professional and pleasant environment.

Summer Allergies vs. Summer Cold

summer cold vs summer allergiesSo, you have a runny nose, nasal congestion, sneezing, post-nasal drip, sore throat and coughing and it is the Summertime. Are you confused? You thought allergies occur in the Spring and Fall. You thought that “colds” occur in the Fall and Winter. Well, both “colds” and allergies can occur anytime and Summer is no exception.

“Colds” are caused by more than 200 different types of viruses. Some common viruses responsible for colds may include rhinovirus, other enteroviruses, coronavirus, influenza virus, parainfluenza virus, adenovirus, human respiratory syncytial virus (RSV), and metapneumovirus. Rhinovirus, an enterovirus, is by far the most common cause of the common cold than any other virus. Typically, the symptoms of a “cold” are similar to those of allergic rhinitis (i.e., hay fever). In addition to the classic sneezing, runny nose, nasal congestion, and post-nasal drip of allergic rhinitis, individuals with “colds” may also have other symptoms that may include sore throat, coughing, headaches, fatigue, achiness, fevers, chills, and/or discolored nasal discharge. It should be noted that discolored nasal discharge, fevers, and chills do not occur in most individuals with a common cold. In patients who have the influenza virus (i.e., flu), achiness, headaches, and fever are much more common than in individuals who only have the common cold.

In contrast to “colds” which are caused by viruses, Summer allergies are caused by common environmental allergens. The most common allergens found in the Summer include grass pollen, weed pollen, molds, dust mites, cockroaches, and pets (e.g., cat, dog, birds). Occasionally some tree pollen may cause some Summertime allergies in the Washington, DC, Northern Virginia, and Maryland metropolitan area, but in general, trees pollinate in the Spring and are not much of a nuisance by the time Summer rolls around. Grass pollen tends to become a problem in May and it may continue to be irritating to allergy sufferers until August. Ragweed usually begins to pollinate in mid-August and is generally done pollinating by the first frost in October. Molds, dust mites, cockroaches, and pets are perennial allergens and can bother allergic individuals throughout the year, including the Summer. Molds are found both indoors and outdoors and tend to be worse in damp places in the house such as kitchens, bathrooms, and basements, although mold can be anywhere in the house. Dust mites, cockroaches, and pets are indoor allergens, although pets can transfer outdoor allergens (i.e., pollens) to the inside of a house by means of their coats, as pollen may stick to the pet’s hair or fur.

The diagnosis of whether the “allergy” symptoms are a result of allergies or of a “cold” depends on many factors. The length of time one has had symptoms, auxiliary symptoms (i.e., sore throat, coughing, headaches, fatigue, achiness, fevers, chills, and/or discolored nasal discharge), other effected individuals, and response to treatment all play a role in diagnosing the cause of the symptoms. Typically, a “cold” lasts about 1 week in duration unlike allergic rhinitis which generally last at least a season and sometimes is perennial in nature. If other individuals that live in the same household have similar symptoms, a “cold” should be thought of as the cause before allergies. Supplementary symptoms to the classic allergic rhinitis symptoms such as sore throat, coughing, headaches, fatigue, achiness, fevers, chills, and/or discolored nasal discharge should trigger the allergist to think of a “cold” or flu before allergies as a cause. Lastly, the response to the treatment that an individual tries may also help the allergist determine the cause of the symptoms, be it an allergy or a “cold.”

The treatment of the symptoms may be similar regardless of whether the symptoms are a result of allergies or a “cold.” Symptomatic treatment typically may include oral antihistamines, nasal antihistamines, nasal corticosteroids, decongestants, and/or analgesics. Ongoing treatment may be needed in individuals with allergic rhinitis, whereas symptoms typically abate on their own within 1 week in individuals who have a “cold.”

Regardless of whether you have allergies or a “cold,” it should be emphasized that the classic symptoms of allergic rhinitis (i.e., sneezing, runny nose, nasal congestion, post-nasal drip) may occur at any time of the year. Yes, even Summer. Whether or not the symptoms are due to allergies or are a result of a “cold” however is another story. Either way, seeking the advice of a board certified allergist is an important step in determining the ultimate cause as well as finding the solution to reduce and hopefully eliminate those unwanted and annoying symptoms.

The board certified allergists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC metropolitan area. Our office locations are in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Each office has on-site parking 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. Our allergists see both adult and pediatric patients. To make an appointment, please call our office location that is most convenient for you or 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 strive to provide our patients with the highest quality allergy, asthma, and immunology care in the Washington, DC, Northern Virginia, and Maryland metropolitan area.

Epinephrine Nasal Spray

Allergic reactions can sometimes be life-threatening. Anaphylaxis is a severe allergic reaction that is characterized by a sudden onset of symptoms with rapid progression. The manifestations may include generalized itching (i.e., pruritus), hives (i.e., urticaria), swelling (i.e., angioedema) of soft body parts, rapid pulse rate, a precipitous drop in blood pressure, dizziness, nausea, vomiting, abdominal pain, wheezing, shortness of breath, and/or loss of consciousness. Anaphylactic reactions are usually triggered by allergies to foods (e.g., peanuts, tree nuts, fish, shellfish), insect venoms (e.g., bee, wasp, yellow jacket, hornet, fire ant), and/or medications.

Administration of epinephrine immediately after the onset of an anaphylactic reaction usually stops the reaction from progressing and can be lifesaving. Occasionally, more than one dose of epinephrine is needed to reverse the untoward effects of anaphylaxis. Until now, the only approved route of the administration of epinephrine into the body has been through an injection with a syringe and needle. Epinephrine auto-injector devices such as EpiPen, Auvi-Q, and Adrenaclick have been available for several years. These self-injectable epinephrine devices are easy to use and allows the patient to administer epinephrine as soon as early anaphylactic allergic symptoms develop.

On May 11, 2023, an expert panel of advisers recommended to the Food and Drug Administration’s (FDA) that they approve an epinephrine nasal spray product, clearing a key hurdle for what could soon be the first needle-free option for treating severe allergic reactions.

The device which is designed to deposit epinephrine into the nostril is called Neffy. The same device was previously approved to administer a medication called naloxone into the nose to reverse the effects of a narcotic overdose.

Neffy delivers 2 mg. of epinephrine which is suitable for patients weighing above 30 kilograms (66 lbs.). The FDA is likely to decide on the final approval process in the next few months. If approved, the device will be available for use before the end of the 2023 year.

During clinical trials, the epinephrine nasal spray administration was compared with the previously approved injectable epinephrine products (i.e., EpiPen, Auvi-Q, Adrenaclick) in more than 600 individuals. The nasal spray has demonstrated comparable efficacy and rapidity of action, in most cases within a minute of administration. The effects on blood pressure and pulse rate, which were surrogate markers for the reversal of reaction, were non-inferior to injectable epinephrine. When a second dose is needed, the nasal spray showed a slightly better response than with injections. The epinephrine concentrations in the bloodstream also did not differ substantially with either route of administration.

Neffy’s safety profile was comparable with an injection of epinephrine with mild reactions that did not include any meaningful nasal irritation or pain. Intranasal delivery and pharmaco-dynamic response also were effective even with nasal congestion or a runny nose, such as when patients are experiencing allergic rhinitis (i.e. hay fever) or an upper respiratory tract infection (URI).

During clinical studies, the researchers also found that patients are more likely to use the nasal spray much earlier than the injection, which is advantageous in reversing the anaphylactic reaction. The other benefits of the nasal spray are that the nasal spray is more convenient to carry and there obviously was no needle- related injuries since no needle is needed.

If approved by FDA, the intranasal epinephrine could offer a preferred alternative to injectable epinephrine devices and meet an unmet need. Many individuals fail to use self-injectable epinephrine devices when anaphylaxis arises. Some find the pen-style devices inconvenient to carry. Some are reluctant to use them because they are fearful of needles, while others panic when an anaphylactic reaction occurs. Having an epinephrine nasal spray available is a welcome addition to the arsenal of medications used to combat and treat severe allergic reactions.

The board certified allergy specialists at Black & Kletz Allergy has 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking and the Washington, DC and McLean, VA offices are 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 allergists of Black & Kletz Allergy diagnose and treat both adult and pediatric patients. 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. The allergy doctors at Black & Kletz Allergy have been helping patients with anaphylaxis, hives, insect sting allergies, food allergies, medication allergies, hay fever, asthma, sinus disease, eczema, and immunological disorders for more than 5 decades. If you suffer from allergies, it is our mission to improve your quality of life by reducing or preventing your undesirable and irritating allergy symptoms.

Mold Allergy Update

Mold allergies are very common, particularly in the Washington, DC, Northern Virginia, and Maryland metropolitan area. The reason why there appears to be a high prevalence of mold-allergic individuals in the Washington, DC metro area may be tied to the fact that Washington, DC was built on a swamp. The climate in this mid-Atlantic region is conducive to mold growth due to its relative humidity. In the Spring there is a lot of rain. The Summers are very humid. In the Fall, the leaves from trees fall to the ground and subsequently develop “leaf mold” on the leaves due to the decomposition of the leaves by molds. Although decomposition of leaves is an important step in the mineralization of organic nutrients and the recycling of nutrients to plants, it is often met with dismay to allergy sufferers who are allergic to molds.

Molds are fungi that grow in the form of multicellular strands called hyphae. Fungi that circulate in a single celled environment are called yeasts. Molds are a common cause of hay fever (allergic rhinitis) and/or eye allergies (allergic conjunctivitis). Individuals that are allergic to molds may experience sneezing, nasal congestion, runny nose, post-nasal drip, itchy nose, sinus headaches, itchy eyes, watery eyes, and/or redness of the eyes. In some people, molds may cause asthma-like symptoms which may include wheezing, chest tightness, coughing, and/or shortness of breath. In asthmatics, molds may be a triggering factor which can cause a worsening of their asthma symptoms. The treatment of allergic rhinitis, allergic conjunctivitis, or asthma due to mold allergies usually involves reducing the exposure to molds, if possible. Common medications that are used may include antihistamines, decongestants, mast cell stabilizers, topical corticosteroids, anticholinergics, inhaled beta-agonists, leukotriene antagonists, and occasionally biological medications. Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization) is very effective in the treatment of mold allergies as it helps in 80-85% of patients on the injections. The average length of time on allergy immunotherapy is typically 3-5 years.

Not only can molds not cause allergy symptoms, but molds can in fact affect individuals in 3 other major ways: 1. Act as an irritant; 2. Cause infection; or 3. Act as a toxin.

Molds can cause an irritant reaction which is similar to an allergic reaction but this type of reaction is not technically allergic since there is not an immune reaction to the molds. Irritant reactions are also called nonallergic rhinitis. Individuals that have an irritant response to molds typically experience symptoms such as irritated eyes, nose, throats and/or lungs. Examples of irritant reactions include a runny nose after eating horseradish or burning and watery eyes from freshly cut onions. The best treatment of irritant reactions to molds is to avoid exposure to molds. If one cannot avoid exposure, medications may be used to help minimize the symptoms of the irritant reaction. Such medications may include oral antihistamines, oral decongestants, nasal antihistamines, nasal decongestants, nasal corticosteroids, nasal anticholinergics, and/or ocular medications.

Fungi and molds can cause infections in certain individuals, particularly those who are immunocompromised or have a “low” immunity. Individuals can be immunocompromised for a variety of reasons which may include medications (e.g., corticosteroids, tacrolimus, cyclosporine, biological monoclonal antibodies, azathioprine), immunodeficiencies (e.g., hypogammaglobulinemia, Bruton’s agammaglobulinemia, IgG subclass deficiency, common variable immunodeficiency), HIV/AIDS, elderly individuals, radiation, cancer, malnutrition, and stress after surgery, to name a few. Fungi tend to infect the sinuses, brain, eyes, lungs, nails, esophagus, tongue, and/or bloodstream. The fungal infection can be either systemic or superficial. Systemic fungal infections tend to occur more in immunosuppressed individuals and may be life-threatening. It is important to note that superficial fungal infections of the nails, tongue, and skin are common in normal individuals without compromised immune systems. Fungal infections of the lungs, brain, bloodstream, esophagus, sinuses, and eyes that are more problematic and tend to occur more often in patients with compromised immune systems. The treatment of fungal infections varies depending on the severity and location of the fungus. It should be noted that antifungal medications are used to treat fungal infections and may be given orally, topically or intravenously.

Molds may also act as a toxin in a condition called toxic mold syndrome. This syndrome is caused by mycotoxins (i.e., toxins produced by molds) and is sometimes referred to as sick building syndrome. Individuals with this disorder generally complain of a variety of non-specific symptoms as the symptoms may vary greatly from one individual to another. The symptoms may include watery eyes, itchy eyes, red eyes, runny nose, sore throat, rashes, headaches, nosebleeds, nausea, vomiting, dizziness, anxiety, fatigue, lack of concentration, mood swings, poor appetite, insomnia, weight loss, memory loss, hair loss, rashes, chest tightness, coughing, wheezing, and/or shortness of breath. Toxic molds grow most commonly on damp walls and ceilings. Toxic molds tend to manifest as black, brown, or green patches along with an associated musty odor.

The board certified allergists at Black & Kletz Allergy have expertise in diagnosing and treating mold allergies, as well as all types of other allergic conditions and asthma. We are board certified to treat both pediatric and adult patients and have been doing so in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years. 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 mold allergies, we are here to help alleviate or hopefully end these undesirable symptoms so that you can enjoy a better quality of life. Black & Kletz Allergy is devoted to providing the highest quality allergy care in a caring, relaxed, and professional environment.

Mammalian Meat Allergy Update

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

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

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

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

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

Diagnosis:

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

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

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

Management:

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

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

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

Prevention:

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

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

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

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