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Churg-Strauss Syndrome

 

Asthma usually coexists with other allergic disorders such as hay fever (i.e., allergic rhinitis) and/or atopic dermatitis (i.e., eczema). Less commonly, asthma is associated with chronic inflammatory/immunological disorders such as Churg-Strauss syndrome.

Churg-Strauss syndrome is characterized by abnormal and excessive accumulation of types of white blood cells called eosinophils in the blood and tissues leading to tissue damage. Any organ can be affected but the lungs and the blood vessels are most commonly affected. Chronic inflammation of the blood vessels is termed vasculitis or angiitis. Accumulation of eosinophils in tissues may also cause nodular swellings called granulomas. These features give Churg-Strauss syndrome a more descriptive name. Thus Churg-Strauss syndrome is also known as eosinophilic granulomatosis with polyangiitis (EGPA), a type of vasculitis.

The initial clinical manifestations are usually due to from lung involvement resulting in asthma-like symptoms such as coughing, chest tightness, shortness of breath and/or wheezing. These are often followed by generalized systemic symptoms, which take the form of a flu-like illness with fever, fatigue, malaise, loss of appetite, and/or muscle aches (i.e., myalgias).

Vasculitis may cause narrowing of the affected blood vessels, which may result in the blocking or slowing of the flow of blood to various organs and tissues of the body. Inflamed blood vessels may also become thin and fragile, potentially rupturing and bleeding into the surrounding tissues. In addition, the blood vessels may become stretched out causing the development of a bulge in the vessel wall (i.e., aneurysm).

As Churg-Strauss syndrome can affect multiple organ systems, the presentation varies widely from person to person. Involvement of the upper airways is very common, causing rhinitis and chronic or recurrent sinus infections. Excessive tissue growth may result in polyps in the nose and sinuses. Fluid may accumulate in the middle ear causing serous otitis media. Inflammation of the membrane covering the eyeballs is called conjunctivitis and leads to itchy, red eyes and occasionally blurry vision.

Approximately 75% of patients experience nervous system involvement. The neurological symptoms may include chronic pain, the feeling of tingling and numbness, muscle weakness, and/or loss of motor function resulting in paralysis. Blood clots in the blood vessels of the brain and/or bleeding may cause strokes. Gastrointestinal involvement may result in abdominal pain, nausea, vomiting, diarrhea, blood in the stools, and/or inflammation of the membrane lining the large intestine.

Skin lesions develop in about half the patients with Churg-Strauss syndrome and may include purplish spots due to bleeding into skin (i.e., purpura), hives (i.e., urticaria) and/or nodules. Heart abnormalities are caused by inflammation of the blood vessels and the development of nodular lesions within the heart tissue. Symptoms associated with heart disease may include fatigue, shortness of breath, palpitations, chest pain, and/or fainting (i.e., syncope) episodes. Involvement of kidneys is rare however if involved, it may lead to high blood pressure and/or renal failure.

Causes:

The exact cause of Churg-Strauss syndrome is not clearly established. Most researchers believe that several different factors such as genetic, environmental, and immunological abnormalities may play a role in the development of the disorder. It is classified as an autoimmune disorder. Autoimmune disorders are caused when the body’s natural defenses against “foreign” or invading organisms begin to attack healthy tissue for unknown reasons.

The disorder can affect individuals of almost any age and but generally ranges from 15 to 70 years of age. The incidence in males is slightly higher than in females. It is more commonly seen in families who also have history of other allergic disorders.

Diagnosis:

An individual is classified as having Churg-Strauss syndrome if 4 of the following 6 findings are identified:

  • Asthma
  • Fleeting lung infiltrates consistent with imitating pneumonia on chest X-rays or CT scans
  • Neuropathy – Nerve damage
  • Abnormality of the sinuses – Recurrent or chronic sinus infections is common
  • Eosinophilia – Defined as greater than 10% eosinophils in the circulating blood
  • Eosinophils outside the blood vessels such as in tissues and organs

In approximately 50% of the patients, blood tests reveal the presence of a specific type of proteins called antineutrophil cytoplasmic antibodies (ANCA). Chest X-rays, sinus X-rays, CT scans and/or tissue biopsies may be needed to confirm the diagnosis.

Treatment:

Initial treatment may include oral or injectable corticosteroids (e.g., prednisone) in order to control excessive inflammation in the blood vessels and other tissues. High doses of corticosteroids are usually used in the beginning with a gradual taper to minimize the risk of side effects. Side effects of corticosteroids may include elevated blood sugars, weight gain, bone problems due to bone loss, cataracts, ulcers of the stomach, depression, and an increase in infections.

Patients who do not respond to corticosteroid medications may need immunosuppressive and/or cytotoxic medications (e.g., methotrexate, cyclophosphamide). Some patients may need monthly infusions of immunoglobulins either intravenously or under the skin (subcutaneously).
In 2017, Nucala (mepolizumab) was approved by the U.S. Food and Drug Administration (FDA) to treat adult patients with Churg-Strauss syndrome. It is a biologic medication that is injected under the skin every 4 weeks. It works by blocking a cytokine called IL-5 (i.e., interleukin-5) which is needed for growth and differentiation of eosinophils. In 2018, the FDA granted orphan drug designation ODD for Fasenra (benralizumab), another biologic medication used to treat Churg-Strauss syndrome.

Early initiation of treatments as soon as the diagnosis is made, can help prevent tissue damage and long-term complications.

The board certified allergists at Black & Kletz Allergy have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area and treat both adults and children with asthma, Churg-Straus syndrome, sinus disease, hay fever (i.e., allergic rhinitis), nasal polyps, other allergic and immunologic disorders. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Black & Kletz Allergy offers on-site parking at each of their 3 convenient office locations and the Washington, DC and McLean, VA offices are also 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 any of our offices or you can click Request an Appointment and we will respond within 24 hours on the next business day. Black & Kletz Allergy has been serving the asthma and allergy needs of the Washington, DC metropolitan area for more than 50 years. We strive to provide high quality allergy and asthma care in a caring professional environment.

Oak Mites

If you have been doing yardwork this Summer, you may have noticed a multitude of red swollen itchy hive-like marks that seem like some sort of bug bite all over your body. You may be correct and these bug bites may well be caused by oak mites. Other names for oak mites include oak leaf gall mites, oak tree mites, and itch mites. Oak mites probably originated in Europe but have been in North America since the early 2000’s. They have increased in frequency in the U.S. ever since. They tend to be more of a nuisance in the Summer and Fall. Oak mites are microscopic and contain 8 legs. Since they have 8 legs, they are considered arachnids, like a spider or a tick. They are technically not insects because insects have 6 legs.

Normally, oak mites tend to hide in oak galls. Oak galls are unusual deformities (i.e., swellings) of plant growth comprised of plant tissue commonly on foliage caused by chemicals that regulate plant growth which are produced by insects or arthropods. Oak mites usually feed on midge fly larvae in these oak galls. This year, however, oak mites have also feasted on cicada eggs. The oak mites fall out of oak trees while eating cicada eggs, land on humans, and then bite them. Keep in mind that oak mites can fall out of trees in very large numbers, sometimes more than hundreds of thousands at a time. Oak mites are also carried off by the wind and can spread to other trees in this manner.

As mentioned above, this year in particular, the number of oak mites have increased almost exponentially in certain areas of the U.S. including the Washington DC, Maryland, and Virginia region. This Summer brought the reemergence of the 17-year Brood X cicadas, and as a result, oak mites have come out in full force in the Washington, DC metropolitan area in hopes to thrive on the plentiful cicada eggs. The good news is that once that food source (i.e., cicada eggs) is gone, the numbers of oak mites will diminish greatly.

Since oak mites are microscopic and cannot be seen with the naked eye, the bites are even more frustrating since they appear on the skin almost like magic. The bites can be numerous and overwhelming. In addition to biting exposed skin (e.g., arms, neck, face), oak mites can bite under loose clothing and/or between the hairs on the head.

You may wonder what you can do in order to avoid oak mite bites. Some avoidance measures may include the following:

  • Avoid congregating under trees, especially in the Summer and Fall
  • Wear protective clothing including hat and gloves when in the woods or under a tree
  • Wash clothes and put dryer on medium temperature after being near trees
  • Keep house doors and windows closed
  • Shower after being outside near trees

The treatment of oak mite bites is pretty basic and involves some common sense remedies. The use of over-the-counter antihistamines (e.g., Benadryl, Claritin, Allegra, Zyrtec) may be beneficial to help with associated itching and swelling. Over-the-counter Hydrocortisone creams may also help the itching as well as reduce the size and duration of the hive-like reactions from the bites. It may also be advantageous to apply a cold compress to the oak mite bites to help prevent swelling, if possible.

The board certified allergy doctors at Black & Kletz Allergy treats both adults and children and will gladly answer any questions you have concerning oak mite and insect bites. Black & Kletz Allergy has 3 offices in the Washington, DC, northern Virginia, and Maryland metropolitan area with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at each location and the Washington, DC and McLean offices are also Metro accessible. There is a free shuttle that runs between our McLean office and the Spring Hill metro station on the silver line. If you would like to make an appointment with our allergy specialist, please call us 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 providing quality allergy, asthma, sinus, and immunological services to the Washington, DC metro area for more than 50 years.

Common Variable Immunodeficiency

Our immune system defends us against microorganisms that cause infections. It also protects us from certain cancers. Thus when the immune system functions sub-optimally, we are more susceptible to infections and cancers.

Common variable immunodeficiency (CVID) is one of the most common conditions where the immune system is deficient or less functional.

Causes:

It is thought that genetic defects are most likely the underlying cause for this condition, although specific gene defects were identified in only 10% of the cases. Common variable immunodeficiency is known to occur more commonly in certain families which also suggests a genetic cause.
Males and females are equally affected in CVID. Common variable immunodeficiency occurs in approximately 1 out of every 25,000 individuals. Even though the condition is present from early childhood, it is most commonly diagnosed in the second or third decades of life.

Symptoms:

The most common presentation of CVID involves recurrent infections involving various organ systems. The infections are typically as specified below:

  • Upper respiratory and/or sinus infections
  • Ear and/or throat infections
  • Bronchitis and/or pneumonia
  • Gastrointestinal infections
  • Neurological infections
  • Fatigue, joint pains (i.e., arthralgias), and/or muscle pains (i.e., myalgias)

The infections can vary in severity from mild to severe. Many patients require emergency room visits and/or hospitalizations for the management of severe infections.

Physical examination sometimes reveals enlarged lymph nodes and rarely skin rashes.

Diagnosis:

The diagnosis of common variable immunodeficiency is initially suspected on the basis of a history of recurrent infections for a number of years, often with unusual or rare organisms.

Confirmation of the diagnosis is completed by blood tests which reveal lower numbers of lymphocytes and antibodies (i.e., proteins that fight infections) compared to normal reference levels. Measuring antibody levels before and after vaccinations is also helpful in testing the ability of the immune system to manufacture specific antibodies. It should be noted that CVID patients cannot respond to immunizations adequately and thus do not mount a good immune response to vaccinations.

Treatment:

  • Antibiotic treatment for infections: Patients need prolonged courses of antibiotics in order to adequately treat severe bacterial infections.
  • Prophylactic antibiotics: Patients require prophylactic antibiotics in order to prevent infections prior to surgical and/or dental procedures.
  • Antibody supplementation: Most patients need regular infusions of antibodies, which are pooled from donors, either through a vein (i.e., intravenous) or under the skin (i.e., subcutaneous) on a regular basis. This treatment maintains the integrity of the immune system and helps prevent frequent and repeated infections. This treatment, known as gamma globulin therapy (i.e., immunoglobulin therapy, antibody replacement therapy), needs to be continued lifelong, as there is no cure for common variable immunodeficiency.

Complications:

Patients with CVID are more likely to develop autoimmune disorders affecting the thyroid gland, liver, and connective tissues. Autoimmune conditions may also attack blood cells resulting in anemia and/or low platelet counts. Low platelet counts usually manifests itself as easy bruisability and/or increased bleeding.

Individuals with common variable immunodeficiency are also more susceptible for certain types of cancers and granulomas (i.e., inflammatory swellings) in the skin, lymph nodes, stomach, and/or liver. For this reason, patients need regular monitoring, surveillance, and screening for these type of cancers. It is recommended that all individuals with this disorder follow up with their primary care physician on a routine basis in order to be diligent in this regard.

Prognosis:

With regular antibody replacement therapy, prophylactic and curative antibiotic regimens, and close monitoring for complications, most individuals with CVID can lead long and fulfilling lives.

The board certified allergy doctors 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 immunodeficiency disorders such as common variable immunodeficiency. Black & Kletz Allergy treat both adults and children 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. The allergy specialists at Black & Kletz Allergy have been serving the Washington, DC metropolitan area for more than 5 decades. We pride ourselves in providing excellent immunological care as well as exceptional allergy and asthma care in a professional and friendly setting.

Reactions to Food Additives

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

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

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

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

Sulfites:

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

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

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

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

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

Food Dyes:

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

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

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

DIAGNOSIS:

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

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

PREVENTION:

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

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

More and more natural and artificial chemicals are being added to our food as preservatives, flavor enhancers, and coloring agents.  The U.S. Food and Drug Administration (FDA) lists close to 4,000 substances as food additives.

Despite widespread use of these chemicals in food, adverse reactions are fortunately uncommon.  Most cases are described in the literature as single case reports or reports of a small cluster of patients.

Preservatives:

Sulfites:  These chemicals in the gaseous form can cause lung irritation and may trigger asthma in sensitive asthmatics.  They are commonly found in liquid form in processed cold drinks and fruit juice concentrates in order to extend their shelf lives.  Sulfites are also added to most wines and sprayed onto cut foods in order to keep them fresh and prevent discoloration or browning. They are used to preserve smoked and processed meats, dried fruit (e.g., apricots), and salads.  In its solid form, sulfites can cause hives when ingested.

Benzoic acid (i.e., benzoate) and Parabens:  Benzoates and parabens have antibacterial and anti-fungal properties in order to help with the prevention of food spoilage.  These agents are added to pharmaceutical and food products such as drinks (e.g., sugar-free cola). They occur naturally in prunes, cinnamon, tea, and berries.  These substances may cause urticaria (i.e., hives), asthma and angioedema (i.e., swelling) in sensitive individuals.

Antioxidants:  Synthetic phenolic antioxidants [e.g., BHA (butylated hydroxyanisole) and BHT (butylated hydroxytoluene)] are typically added to processed foods such as dry cereals and potato flakes in order to prevent the fats and oils in these foods from turning rancid when exposed to air.  Unfortunately these antioxidants may trigger asthma, rhinitis, and urticarial in some sensitive individuals.

Flavor Enhancers:

Aspartame (e.g., NutraSweet, Equal), a low-calorie sweetener, can occasionally trigger itchy hives and swelling of the body.  It is also important to note that individuals with genetic condition phenylketonuria should avoid aspartame. Aspartame breaks down into an essential amino acid called phenyalanine which is toxic to individuals with phenylketonuria since these patients are unable to metabolize phenyalanine.

Colorings:

Azo dyes [e.g., tartrazine (i.e., yellow dye #5)] and Non-azo dyes (e.g., erythrocine) can trigger hives, asthma, and generalized allergic reactions.

Nitrates and Nitrites give meat a pink color to look more attractive.  These food colorings are typically found in bacon, salami, and frankfurters.

Monosodium Glutamate (MSG) may trigger the “Chinese Restaurant Syndrome” which causes individuals to experience headaches as well as burning and/or tightening of the chest, neck, and face.  MSG may be found in soups, pot noodles, and instant drinks, among other foods.

Naturally Occurring Substances:

Vasoactive amines: Natural histamine, serotonin, and tyramine occur in some ripe cheeses, fish, cured sausage, red wine, chocolate, and pickled vegetables and may induce cramping, flushing, headache, and palpitations in a dose-related manner.  Of note, there is a condition known as “scombroid poisoning” which occurs in individuals who eat spoiled fish. In this condition, there are abnormally high quantities of histamine in the fish due to improper storage or processing.  The typical fish affected may include tuna, mackerel, herring, sardine, anchovy, marlin, and bluefish. The symptoms may include flushing, headache, generalized itching, blurred vision, abdominal cramps, and/or diarrhea. Scombroid poisoning is often wrongly diagnosed as a fish allergy since similar symptoms may be associated with a true fish allergy.  One key factor to look for is to see if other individuals eating the same piece of fish exhibited symptoms. If so, it is more likely to be scombroid poisoning due to eating spoiled fish as opposed to a fish allergy.

Caffeine found in foods, medication, tea, coffee, and carbonated beverages induces dose-dependent agitation, palpitations, nausea, and/or tremors.

Salicylates (i.e., aspirin-like naturally occurring chemicals) may induce urticaria, asthma, and/or nasal polyp growth.  They are found in curry powder, paprika, oranges, apricots, ginger, honey, berries, fruit skins, tea, and almonds.  Salicylate sensitive individuals also tend to have adverse reactions to benzoates and tartrazine.

Diagnosis:

The precise mechanism how food additives cause reactions is not well understood in many instances.  The IgE antibody, which plays a crucial role in immediate-type (i.e., Type I) allergic reactions to food, is usually not involved in adverse reactions caused by food additives.

Skin prick tests and allergy blood tests are not helpful in identifying the food additive culprit in most cases.  Careful observation and maintaining food and symptom diaries are sometimes useful in narrowing down the offending additive. Oral challenges under close monitoring in controlled environments may be needed to arrive at a specific diagnosis.

Management:

Avoidance of the suspected food additive is the only certain way of preventing adverse effects.  One should be vigilant about reading food labels and asking restaurants about ingredients and cooking methods.

If there is a history of anaphylaxis, carrying an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) is extremely helpful in emergency treatment.  It is important to emphasize that if a self-injectable epinephrine device is used, one should go immediately to the closest emergency room.

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

Pregnancy and Allergies

 

Asthma and allergies are quite common in pregnancy. Although complications from asthma and allergies are much less common, approximately 1% of pregnant women suffer from asthma during their pregnancy. Many more suffer from allergic rhinitis (i.e., hay fever) and other allergies (e.g., food, medication). Allergy symptoms due to allergies tend to be worse in pregnancy for approximately one-third of women, better in another one-third, and about the same as before pregnancy for the other one-third. It is important to note that it is also possible to develop new allergies during pregnancy.

Many women without a previous history of allergies complain of allergy symptoms during pregnancy. In some of these women, they indeed have developed allergies. In others, the allergy symptoms are present, but there is no definitive allergy. In these latter women, their elevated estrogen and progesterone levels are responsible for the typical nasal congestion that they may be experiencing. The increased hormone levels cause one’s mucus membranes to swell. When this swelling affects the nose, nasal congestion is the result. The diagnosis of hormone-induced nasal congestion of pregnancy is then justified if the hormonal elevation alone is responsible for the nasal congestion. Note that in addition to the nasal congestion, some nonallergic pregnant women who have hormone-induced nasal congestion of pregnancy may also experience a post-nasal drip and an associated cough due to the post-nasal drip.

The most common allergies during pregnancy are not any different than in non-pregnant women. Allergic rhinitis symptoms during pregnancy are still due to the same common allergens which usually include pollens, dust mites, molds, pets (e.g., cats, dogs), and cockroaches. The classic symptoms still may include sneezing, runny nose, itchy nose, nasal congestion, post-nasal drip, itchy throat, sinus congestion, sinus headaches, itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes. In asthmatic individuals, wheezing, chest tightness, coughing, and/or shortness of breath may also occur. It should be emphasized that the lack of sneezing and itching in a pregnant woman with nasal congestion should be a red flag to consider a diagnosis of hormone-induced nasal congestion of pregnancy, as opposed to the classic allergic rhinitis in a pregnant individual.

The diagnosis of allergic rhinitis and/or asthma while pregnant begins with a comprehensive history and physical examination history performed by a board certified allergist, like the ones at Black & Kletz Allergy. Allergy blood tests may be ordered to diagnose a pregnant patient. Allergy skin testing is generally not performed on pregnant women.

Once the diagnosis is made, the focus turns to treatment. Treatment of allergic pregnant women is similar to non-pregnant women however the medications used to treat pregnant women are more limited. Only medications that have a Category B pregnancy rating and occasionally a Category C pregnancy rating (if needed) are generally used. There are antihistamines, nasal sprays, leukotriene antagonists, and asthma inhalers that are Category B which are utilized first in the treatment of allergic rhinitis and asthma. Most of the time, improvement can be obtained by using just Category B pregnancy medications. Pregnant women should be cautious before using any medication while pregnant, particularly during the first trimester. Pregnant women should get approval from their Ob/Gyn physician before using any medication, even if prescribed by another physician.

Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization) can be continued in pregnant women. Individuals however are not started on allergy immunotherapy if one is already pregnant.

One other important caveat regarding the treating allergies in both allergic and nonallergic patients is the concept of avoidance. It is always recommended to avoid the offending allergen whether it is in the environment (e.g., pollens, molds, dust mites, pets), in the food (e.g., peanuts, shellfish, nuts, fish), or anywhere else. Avoiding what one is allergic to is always the best alternative if possible.

The board certified allergists at Black & Kletz Allergy have been treating pregnant and lactating women for many years. 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 assessable. We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Please call us to schedule an appointment or you can click Request an Appointment and we will reply within 24 hours by the next business day. The allergy specialists of Black & Kletz Allergy are eager to help you with your allergy, asthma, and immunology needs. We are dedicated to providing exceptional care and service to you as we have been doing in the Washington, DC metro area for more than 50 years.

Pork-Cat Syndrome

Pork-cat syndrome is a condition in which individuals become allergic to pork following exposure and sensitivity to cats.  It almost always occurs in individuals who have or have had cats.

Typically, if one is sensitized to cat allergen, the allergic symptoms one may develop are generally triggered by exposure to the cat allergen from the air.  These allergic rhinitis (i.e., hay fever) symptoms may include itchy eyes, red eyes, watery eyes, sneezing, nasal congestion, runny nose, post-nasal drip, itchy throat, sinus pressure, and/or sinus headaches.  Cat allergen may also trigger and/or aggravate asthma symptoms in some individuals and cause coughing, wheezing, chest tightness, and/or shortness of breath.  The treatment for classic cat allergies includes avoiding exposure to cats, medications to relieve the symptoms, and/or allergy immunotherapy (i.e., allergy injections, allergy shots, allergy desensitization, allergy hyposensitization).  Medications may include oral antihistamines, oral decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, nasal mast cell stabilizers, ocular antihistamines, and/or ocular mast cell stabilizers.  The use of oral corticosteroids, nasal decongestants, ocular corticosteroids, and ocular decongestants are discouraged due to their side effects and/or “addictive” qualities.

What is common between cat and pork allergies?

Cat-allergic individuals are also more likely to develop food allergies, particularly to meat, than that of the general population.  The most common type of food allergy related to a history of a cat allergy is that of an allergic reaction to pork.  The symptoms generally begin within an hour after the ingestion of pork.  The usual symptoms may include generalized itching (i.e., pruritus) and/or breaking out in hives (urticaria).  These symptoms can be followed by abdominal cramping, nausea, and diarrhea.  Rarely, more severe reactions such as a sudden drop in blood pressure or throat swelling, which can cause a difficulty in swallowing or breathing, or life-threatening anaphylaxis may occur.  Needless to say, allergic reactions need to be quickly identified and treated with medications in order to stop them from progressing to anaphylaxis.  As meat allergies cannot be desensitized at this time, sensitized individuals should avoid exposure to meat at all times.

The reason that some cat-sensitized individuals are susceptible to pork allergies is that some individuals are not only allergic to the cat dander, but are also allergic to a protein found in cats called albumin.  Albumin is also found in meat from pigs and other animals.  The albumins share several common amino acid sequences.  This phenomenon is termed cross species cross-reactivity.  When albumin is consumed after eating pork meat, an allergic reaction may occur in some cat-sensitive individuals (i.e., in patients that are allergic to cat albumin).

The diagnosis is suspected when a person with a history of allergies to cat also reacts to pork.  It is confirmed by the demonstration of the presence of specific antibodies to both cat and pork allergens.  This is accomplished by skin prick testing and/or laboratory tests.  Skin tests with raw pork are usually positive but with baked meat can be negative since the heat often denatures the protein.  An oral food challenge to pork may sometimes be needed to establish the diagnosis.

This condition should be distinguished from the more common allergies to mammalian meat caused by antibodies to a carbohydrate called alpha-gal.  This condition, which is known as mammalian meat allergy, usually follows a tick bite which introduces the allergen into humans.  In this condition, the symptoms usually begin several hours after ingestion of mammal meat (e.g., beef, pork, lamb, venison) as a “delayed anaphylaxis.”  The diagnosis is confirmed by the detection of specific IgE antibodies to alpha-gal in a blood test.  Some individuals with this condition will have their sensitivity reduced after several years of avoiding the ingestion of mammalian meat.

The management of pork-cat syndrome entails reducing exposure to cats as well as avoiding of pork at all times.  Some individuals will be able to tolerate well-cooked pork, as high temperatures can denature the offending protein and render it less harmful.  Most patients with this condition also need to carry self-injectable epinephrine for emergency use in case of a severe reaction after the accidental exposure to pork.

The board certified allergy doctors at Black & Kletz Allergy have 3 office locations in the Washington, Northern Virginia, and Maryland metropolitan area.  The allergy specialists at Black & Kletz Allergy treat both pediatric and adult patients.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 of our offices have on-site parking and both the Washington, DC and McLean, VA offices are Metro accessible.  In addition, the McLean, VA office has 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.  The allergists at Black & Kletz Allergy have been helping patients with food allergies, hay fever, asthma, eczema, sinus disease, hives, insect sting allergies, immunological disorders, and medication allergies for over a half a century.  If you suffer from any allergy, whether unusual or not, it is our mission to improve your quality of life by reducing or preventing your unwanted and bothersome allergy symptoms.

Allergies to Pets

Do you suffer from allergy symptoms when you go near a pet? Do you suffer chronic allergy symptoms when living in the presence of a pet? If you answered yes to either of the above questions, then you may in fact have a pet allergy. The classic symptoms in someone who has a pet allergy may include sneezing, nasal congestion, runny nose, post-nasal drip, itchy nose, itchy eyes, redness of the eyes, watery eyes, itchy throat, sinus pressure, and/or sinus pain. The official medical term for these symptoms is allergic rhinitis in an individual who is allergic to pets. The same symptoms are also found in allergic individuals who are allergic to dust mites, molds, and/or pollens. Some individuals may experience wheezing, chest tightness, shortness of breath, and/or coughing when exposed to pets. These individuals are said to have pet-induced asthma. Unlike allergic rhinitis, asthma can be life-threatening and thus must be dealt with in a serious manner.

In pet-allergic individuals, the offending allergen is usually the pet dander, saliva, or urine. Depending on the pet, the allergen may be more likely to be the dander, saliva, or urine. In dogs, Can f 1 is the primary dog allergen. This major dog allergen tends to mostly be in the dander of dogs. In cats, Fel d1 is the primary cat allergen. It is primarily secreted through the sebaceous glands and is found mostly on the skin or fur. In addition, another common cat allergen by the name of Fel d 4 is produced in the salivary glands and secreted into the saliva of cats. The licking of the fur by a cat is the perfect storm for cat-allergic individuals as they are exposed to dander that is covered in cat saliva exposing the cat-allergic individual to more cat allergens. Still other pets (i.e., mice, rats) have their major allergens produced in their urine. The major allergen found in mice is known as Mus m 1. This allergen tends to be found more in the urine of mice. In these 3 examples above, it is important to note that major pet allergens can be found in various places in the animal which depends on the specific pet.

Another way that pets can contribute to one’s allergies includes it being a vector to carrying other non-pet allergens to the allergic individual. In other words, pets act as a carrier of other allergens, most notably pollen allergens. When a dog is outdoors for a prolonged period of time, pollen can fall on its fur/hair. This in turn may cause a problem for an individual with pollen allergies once they come in contact with the pollen-covered dog. It is for this reason that it is recommended to wash your pet after a prolonged exposure outdoors, particularly in the Spring or Fall, when pollen counts are the highest.

Some individuals with pet allergies may experience skin manifestations upon exposure to pets irregardless if they have associated allergic rhinitis or asthma. Some may develop eczema (i.e., atopic dermatitis) while others may develop urticaria (i.e., hives).

The diagnosis of pet allergies is usually confirmed by a board certified allergist like the ones at Black & Kletz Allergy. After an initial comprehensive history and physical examination, allergy skin testing is usually done in order to verify a true IgE-mediated allergy to the specific pet (e.g., dog, cat, rabbit, horse, mouse, rat, guinea pig, hamster, bird). Occasionally allergy blood tests may be utilized in addition to or instead of allergy skin testing.

The treatment of pet allergies usually begins with avoidance. It is always preferable to avoid the offending allergen if at all possible. It is also known that people love their pets and usually will not voluntarily part with them. Knowing this, there are a variety of treatment modalities ranging from medications to allergy shots. Medications may include oral antihistamines, oral decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, ocular antihistamines, ocular decongestants, and ocular mast cell stabilizers. Oral and ocular corticosteroids are rarely used due to the potential side effects. Allergy shots (i.e., allergy injections, allergy desensitization, allergy immunotherapy, allergy hyposensitization) are a very effective tool to treat pet allergies. They have been used in the U.S. for more than 100 years. They can be given to both children and adults. Allergy shots are effective in 80-85% of individuals who take them. They can be given in combination with other allergens that an individual may be allergic to such as pollens, dust mites, and molds.

If you have or think you have pet allergies, the board certified allergy specialists at Black & Kletz Allergy have been diagnosing and treating patients with pet allergies for over 50 years in both children and adults. We have office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. Our Washington, DC and McLean, VA offices are Metro accessible and there is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. The allergists at Black & Kletz Allergy are extremely knowledgeable about the most current treatment options for patients with allergic rhinitis, allergic conjunctivitis, and asthma 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. As mentioned before, 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 welcoming and pleasant environment.

Lupin Allergy

Lupin is a legume and belongs to the same plant family as peanuts. In some countries, it is widely grown as a flowering plant for animal feed. In other countries, lupin beans, which are actually the seeds of lupin, are used in the human diet. Lupin beans are high in antioxidants, dietary fiber, and protein and low in starch. Lupin beans can be processed into flour or bran and is used to add fiber, texture, and protein in food manufacturing. The beans may be eaten whole, boiled, or dry and are a common snack in Europe and Asia. Lupin is a particularly common food in the Mediterranean region and in Asian countries. In this global world, lupin is now becoming more common in North America, although most Americans have not heard of lupin.

Lupin is used as an ingredient in a variety of products. These products are very diverse and may include baked goods (e.g., bread, biscuits, rolls, cakes, cookies), pasta, sauces, salads, lupin hummus spreads, chocolate spreads, stews, and ice creams. Some fish and meat dishes (e.g., sausage, hamburger) may also contain lupin. Drinks may also contain lupin as a milk or soy substitute. Lupin is gluten-free and may be found in gluten-free products as a substitute for wheat, rye, or barley. Lupin-derived ingredients are good alternatives for gluten-containing flours and are regularly being used in gluten-free products. It should be noted that there are various other names for lupin some of which may include lupin seed, lupine, lupini, lupinus, altramuz, hasenklee, tarwi, termes, termos, and turmus.

Lupin allergy is much more common in individuals with a history of a peanut allergy, though it can occur in individuals who can tolerate peanut products. Cross-reactivity between peanut and lupin, as investigated by rates of skin prick testing, has been reported to be as high as 44%. Still, for most individuals, lupin beans and lupin flour is safe to eat, although there is an increasing number of case reports of allergic reactions after exposure to lupin-containing products. The severity of allergic reactions to lupin vary from very mild localized reactions in the mouth to severe life-threatening anaphylaxis.

Symptoms:

The symptoms of an allergic reaction to lupin is similar to that of other food allergies. They can manifest as itchy mouth, itchy tongue, itchy throat, itchy eyes, watery eyes, sneezing, nausea, vomiting, diarrhea, abdominal pain, itchy skin, hives and/or other rashes. More severe life-threatening anaphylactic reactions are less common but may present as wheezing, coughing, chest tightness, shortness of breath, dizziness, drop in blood pressure, increased heart rate, and/or loss of consciousness. Uncontrolled asthma is a risk factor for a more severe reaction. Skin exposure to lupin flowers may also cause a contact dermatitis reaction in some sensitized individuals.

Diagnosis:

When the history is suggestive of lupin ingestion and the onset of symptoms occur after exposure to lupin-containing products, the diagnosis can be confirmed by skin allergy prick tests, either to a commercially available testing reagent or with the suspect food itself. Specific antibodies to lupin can also be detected in some laboratory tests. In some cases, an oral food challenge, which is a supervised feeding of gradually increasing amounts of a lupin-containing food, may be conducted in the allergist’s office to determine whether a patient is able to eat and tolerate lupin.

Treatment:

As is the case with other food allergies, avoiding exposure to lupin is the only known way to prevent adverse reactions. It is important to carefully read the labels of packaged foods and also to be aware of possible symptoms of allergic reactions. As of 2006, the European Commission has required that food labels indicate the presence of lupin in food. It should be noted however that in many countries (e.g., U.S., Canada, Australia) emphasis for allergen labeling for lupin is not mandatory as it is for some of the more common food allergens (e.g., peanuts, tree nuts, soy, milk, eggs). It is also important to emphasize that individuals with a history of a severe systemic reaction to lupin should carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) and should receive training in its proper usage. If the self-injectable epinephrine device is used, the individual should go immediately to the closest emergency room.

If you think that you may have lupin or any other food allergy, the board certified allergists at Black & Kletz Allergy would be happy to help you.  We have 3 convenient offices in the DC metro area with office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer on-site parking.  Our Washington, DC and McLean, VA locations are Metro accessible. There is also a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  Please call us for an appointment. Alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day.  The allergists at Black & Kletz Allergy have been treating both adults and children in the Washington, DC metropolitan area for allergies, asthma, sinus disease, and immunologic disorders for more than half a decade.  We strive to provide top-of-the-line allergy relief in a compassionate and professional environment.