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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.


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.


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.


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.

Swelling Episodes (Angioedema)

Swelling episodes may occur randomly in individuals.  The medical term for such swelling occurrences is “angioedema.”  These episodic swellings may occur alone or they may occur in conjunction with hives (i.e., urticaria) and/or generalized itching (i.e., pruritus).  The severity, duration, and location of the swelling episode(s) may vary greatly from one individual to another.  It should also be noted that hives or generalized itching may occur separately without the presence of angioedema.

The most common location for angioedema to occur tends to be on the face, particularly of the eyelids or lips.  The hands and feet are less commonly affected, but are not uncommon.  Swelling of the gastrointestinal and respiratory tracts also occur, but in general, are a rare occurrence.  It is important to realize that swelling of the throat can be life-threatening and those individuals who experience throat tightening should be prescribed a self-injectable epinephrine device such as an EpiPen, Auvi-Q, or Adrenaclick.  Patients should be told that if they use their device, they should immediately go to the closest emergency room.

Angioedema occurs because there is a leakage of fluid through small blood vessel walls which in turn causes soft tissue swelling.

The causes of angioedema can be classified into 4 basic groups:  allergic, non-allergic drug reaction, hereditary, and idiopathic.

Allergic causes of angioedema may include drug allergies [e.g., penicillin, sulfa, vaccines, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs)], food allergies (e.g., peanuts, tree nuts, shellfish, fish, milk, eggs), insect venom allergies (e.g., honey bees, wasps, yellow jackets, hornets, fire ants), and latex allergy (e.g., gloves, condoms, catheters, balloons, dental dams).

The non-allergic drug reactions may include medications from the following classes of medications:  ACE inhibitors (e.g., Enalapril, Lisinopril, Ramipril), angiotensin II receptor antagonists (e.g., losartan, candesartan, olmesartan, valsartan), proton pump inhibitors (e.g., sertraline, citalopram, fluoxetine, escitalopram, paroxetine), selective serotonin reuptake inhibitors (SSRIs) (e.g., omeprazole, pantoprazole, lansoprazole, esomeprazole), and statins (e.g., atorvastatin, pravastatin, simvastatin, rosuvastatin).

Hereditary angioedema is caused by an inherited abnormal gene that causes a deficiency of a normal protein called C1 esterase inhibitor.  This deficiency leads to recurrent swelling episodes which usually begin after puberty.  These swelling episodes are not associated with hives and can either be spontaneous or triggered by infection, alcohol, hormonal changes, physical stress, or mental stress.

Idiopathic angioedema is just a fancy way of saying that we do not know the underlying cause of the swellings.  Autoimmune disorders (e.g., rheumatoid arthritis, systemic lupus erythematosus, Sjögren’s syndrome) may play a role however.

The diagnosis of angioedema may require blood work and/or skin testing depending on the history and physical that is obtained from the patient.  The history is very important and may provide clues to the origin and source of the angioedema.  If the angioedema is recurrent and has re-occurred for more than 6 weeks, blood work is usually ordered in order to rule out an underlying condition that may be the cause of the swelling episodes.  Allergy skin tests may be done in order to rule out food, insect venom, latex, or medication allergies.

The treatment of angioedema depends on the severity and chronicity of the swelling episodes.  In mild acute angioedema, epinephrine injection into the muscle can be performed along with intramuscular injection of an antihistamine and/or a corticosteroid.  An alternative would be oral administration of an antihistamine and/or corticosteroid.  Severe acute angioedema is treated similarly, however, keeping the airway open is the main goal.  For that reason, the use of intramuscular epinephrine is often utilized, particularly if the swelling occurs in the throat or respiratory tract.  The treatment of chronic recurrent angioedema may involve the use of oral antihistamines, H2-blockers, leukotriene antagonists, and/or corticosteroids.  The treatment of hereditary angioedema involves the use of intravenous C1 inhibitor concentrate.  It can also be infused prophylactically about 1 hour before a surgical procedure in order to prevent swellings.  Newer medicines such as Firazyr (icatibant) and Kalbitor (ecallantide) may also be used to treat this genetic condition.

The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating angioedema for more than 50 years.  We treat both pediatric and adult patients.  Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 of our office locations have on-site parking.  For further convenience, our Washington, DC and McLean, VA offices are Metro accessible.  In addition, our McLean office 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 swelling episodes, hives, generalized itching, and/or any other allergy, we are here to help alleviate or hopefully end your undesirable symptoms.  Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

New Treatment for Eczema

Eczema, eczematous dermatitis or atopic dermatitis is a chronic inflammatory condition affecting the largest organ of our bodies, the skin. It is a common long-term disorder which affects about 10-12% of children and 1-2% of adults. In 60% of the cases, onset occurs during the first year of life. The incidence of eczema seems to be increasing in the past few decades and it is more prevalent in developed countries compared with developing countries. Atopic dermatitis is strongly associated with other atopic disorders, such as allergic rhinitis and asthma, with 50-80% of children exhibiting concurrent atopic manifestations.

Genetic factors are predominantly implicated in the causation of eczema, but environmental factors such as allergic sensitivity to certain foods and aeroallergens can play a role in aggravating the condition. In most individuals with eczema, the disease follows a remitting and relapsing course throughout one’s life. Exposure to heat, humidity, and other physical factors may also trigger a flare-up of disease activity.

The hallmark of this condition is a disturbance of epidermal-barrier function due to recurrent skin inflammation, which leads to dry skin, pruritis, and IgE-mediated allergen sensitization. Skin lesions may then lead to increased risks of secondary bacterial and/or viral infections.

In addition to generalized dryness of the skin and scattered rashes over the trunk and extremities, incessant itching is usually the most bothersome symptom. It adversely affects the school performance in children and productivity at work in most adults. Uncontrolled atopic dermatitis may also interfere with nighttime sleep and in general, may have a negative impact on one’s quality of life.

Though there is no cure yet for atopic dermatitis, several treatment options are available to control the activity of the disease process and minimize the intensity of symptoms. Traditional management approaches include:

  • Emollients – These are moisturizing lotions which hydrate the skin in order to relieve the dryness. They need to be applied all over the body when the skin is still wet after a shower or a bath. They seal the moisture into the skin.
  • Topical creams/lotions/ointments – Given in order to reduce inflammation. Corticosteroids are the most common topical anti-inflammatory medications used to reduce the severity of the rash. These agents are available in various strengths and forms. Generally low to medium strength steroids are preferable in order to minimize the side effects such as thinning of the skin and susceptibility to infections. Ointments are preferred to lotions as they can remain on the skin for longer periods. Typically, they are applied twice a day over the affected area for only up to 10 days duration in order to minimize the risks of adverse effects. Ideally, they should not be used over sensitive areas of the body such as the face or groin where they can cause more troublesome side effects such as hypopigmentation. Corticosteroid use in such sensitive areas may also cause higher systemic absorption.
  • Non-steroidal topical anti-inflammatory medications – Protopic (i.e., tacrolimus) and Elidel (i.e., pimecrolimus) are non-steroidal topical anti-inflammatory ointments which are alternative medications to topical steroid medications in the treatment of eczema. They can be used long-term but carry a “black box” warning, as some tumors were noted in rodents exposed to these agents.
  • Eucrisa – A topical agent approved for the treatment of atopic dermatitis. It is available as a 2% ointment and it can be safely used over the face, as it does not cause steroid-related side effects.
  • Dupixent – A biological injectable medication approved for the treatment of uncontrolled asthma as well as atopic dermatitis uncontrolled with topical agents. It works by blocking inflammatory mediators such as IL-4 (i.e., interleukin 4) and IL-13 (i.e., interleukin 13), which contribute to the severity of the disease. The medication is injected under the skin every 2 weeks. The first injection is usually administered in a physician’s offices under close observation and patients are then trained for self-administration of subsequent doses at their homes. Side effects of this Dupixent may include redness and watering of the eyes.
  • Antihistamines – Usually utilized for the control of itching in individuals with eczema. First-generation antihistamines [e.g., Benadryl (i.e., diphenhydramine), Atarax (i.e., hydroxyzine)] are generally more effective at relieving the pruritus (i.e., itching) but they are more likely to cause sleepiness. Second-generation antihistamines (e.g., Claritin, Allegra, Zyrtec) are generally not as effective as the first-generation ones for itching but are less sedating and can be dosed once a day.
  • Oral corticosteroids – Prednisone, an oral corticosteroid, is occasionally used for short-term bursts to control acute flare-ups of the disease. They are not suitable for long-term use due to the risks of adverse side effects.
    Systemic immunosuppressants – Cyclosporine, azathioprine, and methotrexate are immunosuppressants that are rarely used. They are occasionally utilized in order to control severe disease activity; however, their toxicity limits their utility.

As we understand the mechanisms of inflammation in atopic dermatitis in more detail, we are able to target more chemical mediators of disease activity in order to reduce the severity of the symptoms.

Recently, Janus kinase inhibitors or JAK inhibitors have emerged as a novel therapeutic intervention for inflammatory diseases. JAK are intracellular secondary enzyme messengers that transmit extracellular cytokine signaling to the STAT pathway. Inhibition of the JAK-STAT pathway can suppress inflammation and inhibit immune cell activation.

Some of these novel medications which inhibit JAK are currently being used for rheumatological diseases such as rheumatoid arthritis. They are being studied for control of severe atopic dermatitis and clinical trials are revealing very promising results. These JAK inhibitor medications are small molecule agents that are available in both oral [upadacitinib (i.e., Rinvoq), baricitinib (i.e., Olumiant)] and topical [tofacitinib (i.e., Xeljanz)] formulations.

Though none of these medications are yet approved by FDA for the treatment of atopic dermatitis, they remain a promising new therapeutic modality for patients with eczema. They are shown to rapidly and significantly relieve itching as well as reduce the severity of skin lesions.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating eczema for more than 50 years. We treat both pediatric and adult patients. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our locations 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 eczema or other allergic skin conditions, allergies, asthma, or immune disorders, we are here to help alleviate these undesirable symptoms that have been so troublesome, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

Tinnitus – Can It Be Caused by Allergies?

Do you hear ringing, roaring, clicking, buzzing, humming, or hissing sound in your ear or ears? If the answer to this question is yes, then you suffer from a condition called tinnitus. Tinnitus is a disorder in which one classically hears a “ringing” of the ears. As mentioned above, the ringing may also be described as roaring, clicking, buzzing, humming, or hissing. The noise level may be anywhere from very mild to fairly severe. The noise heard is not an external sound but rather in internal sound, not heard by others. Tinnitus affects between 10-20% of the population. It is generally described as a very annoying symptom to those who have had it. Tinnitus is more common in the elderly and can affect one ear or both ears. It can be constant or intermittent. It is more common in the elderly and usually occurs in the presence of another underlying condition such as hearing loss. Some of the underlying conditions that are known to cause tinnitus may include:

  • Hearing loss – Usually caused by loud noises and due to broken hair cells in the inner ear. The hair cells usually move when sound waves are transmitted to the ear. Broken hair cells will interfere with the brain’s interpretation of the sound heard.
  • Ear infections – Fluid build-up will increase the pressure in the ear which can cause tinnitus.
  • Clogged ears – The pressure in the ear can increase from clogged ears due to a foreign body which is not uncommon in children, high altitudes, diving, Eustachian tube dysfunction, acoustic neuroma, or ear wax (i.e., cerumen).
  • Acoustic neuroma – A noncancerous tumor that grows on the main nerve between the ear and the brain.
  • Muscle spasms in the inner ear – The muscles in the inner ear can spasm for unknown reasons that may cause tinnitus.
  • Otosclerosis – Hardening of the bones of the middle ear can lead to tinnitus.
  • Sinus infections – Fluid build-up in the ears or increased pressure of the ears as a result of a sinus infection.
  • Eustachian tube dysfunction – When the Eustachian tube becomes partially or fully blocked, one may develop an ear fullness sensation as well as popping or clicking of the ears. As a result, tinnitus may develop.
  • Ménière’s disease – A build-up of fluid in the compartments of the inner ear, called the labyrinth, is thought to be the cause of this malady. Individuals develop tinnitus, vertigo/dizziness, and hearing loss.
  • Allergies [i.e., allergic rhinitis (hay fever)] – Allergies cause tinnitus usually by causing fluid in the ear or by causing blockage of the Eustachian tubes. In addition, allergic individuals are more likely to have sinus disease.
  • Temporomandibular joint (TMJ) conditions – The TMJ shares some ligaments and nerves with the middle ear. The chewing muscles are also near some of the muscles that insert into the middle ear. Together, these factors may affect hearing.
  • Heart disease – Certain heart problems can increase the blood flow pressure and cause one to have tinnitus.
  • Blood vessel disease – High blood pressure, atherosclerosis, and abnormalities of the blood vessels can cause a higher pressure in the blood vessels which can lead to tinnitus. Pulsatile tinnitus is a condition where one hears their own heartbeat.
  • Thyroid dysfunction – Both overactive and underactive thyroid glands are known to cause tinnitus in some individuals.
  • Medication side effects – Multiple medications are known to have the side effect of tinnitus including aspirin, nonsteroidal anti-inflammatory agents or NSAIDs (e.g., ibuprofen, naproxen), loop diuretics [e.g., furosemide (Lasix)], ACE inhibitors (e.g., lisinopril, enalpril), Accutane, anti-malarial drugs (e.g., chloroquine, hydroxychloroquine), and certain antibiotics (e.g., tobramycin, gentamicin)
  • Hormonal changes – Abnormal estrogen levels have been associated with tinnitus.  Premenstrual syndrome (PMS), perimenopause, menopause, and pregnancy have all triggered tinnitus. As mentioned above, abnormal thyroid levels may also cause tinnitus.

Despite the many causes of tinnitus, some underlying conditions cannot be treated very easily, while others, such as allergies, are easier to treat. Hay fever (i.e., allergic rhinitis) is quite common, as 25-30 million individuals in the U.S. suffer from it. Individuals with allergic rhinitis are more likely to be afflicted with tinnitus. In addition, people with allergic rhinitis are more likely to be bothered with sinus infections, ear infections, clogged ears, and Eustachian tube dysfunction, all of which are additional risk factors for tinnitus. The treatment of allergic rhinitis and/or its associated complications (i.e., sinus infections, ear infections, clogged ears, Eustachian tube dysfunction) can prevent, alleviate, or eliminate tinnitus in many individuals. Medications often used to treat allergic rhinitis may include antihistamines, decongestants, leukotriene antagonists, nasal corticosteroids, nasal antihistamines, and/or nasal anticholinergics. Allergy shots (i.e., allergy immunotherapy, allergy desensitization, allergy injections, allergy hyposensitization) are a very effective tool in the management of allergic rhinitis and asthma and are effective in 80-85% of the patients that take them.

The treatment of tinnitus due to non-allergic underlying conditions may also focus on treating the underlying condition. Examples may include stopping a medication if the tinnitus was caused by a side effect of the medication, hormone therapy in cases of hormonal changes causing tinnitus, or a dental consultation in cases where TMJ is the cause of the tinnitus. It should be noted that treating recalcitrant cases of tinnitus may entail the use of hearing aids, white noise machines and devices, and/or behavioral therapy.

The board certified allergists at Black & Kletz Allergy have been seeing patients with tinnitus 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 accessible and there is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. Please call us to make an appointment or you can click Request an Appointment and we will reply within 24 hours of the next business day. The allergists of Black & Kletz Allergy are eager to help you with your tinnitus or other allergy, asthma, or immunology needs. We are committed to providing excellent care and service to you as we have been doing in the Washington, DC metro area for more than 50 years.

Mast Cell Conditions

Mast cells are a type of white blood cells. They are an important part of our immune system as they help us fight off infections and other invaders. Mast cells contain granules which contain a variety of chemical substances (e.g., histamine, heparin, tryptase, serotonin, leukotrienes, prostaglandins, cytokines). These chemical substances have effects on the body such as inflammation and allergic symptoms.

Mast cells play a crucial role in defending us against infections and aiding in wound healing. Despite these important functions, they can also cause diseases when too many of them are produced (i.e., mastocytosis) or when they become overactive (i.e., mast cell activation syndrome). These fairly uncommon conditions occur in approximately 1 in every 150,000 individuals.


The exact cause of these mast cell conditions is unknown. It is however thought that abnormal genes inherited from parents could play a role in the development of mast cell disorders.


Mast cell disorders can affect various organs in the body:

1. Skin: The skin is the largest organ in our bodies. When excessive numbers of mast cells are deposited in the skin, they cause a condition called urticaria pigmentosa, which manifests as light brown, itchy, and raised patches over various parts of the body. If the patches are rubbed, they become redder, swollen, and may result in blisters (i.e., Darier’s sign). Some individuals also develop dermatographism, which is a condition where one is able to write on the skin with a blunt object. Urticaria pigmentosa is more prevalent in children and usually improves with age. Frequent episodes of flushing, especially over the face, is a common symptom. Generalized itching (i.e., pruritus) can be a very bothersome symptom, interfering with both sleep and work. In addition, the localized accumulation of mast cells can present as nodules.
2. Gastrointestinal: Abdominal pain, bloating, discomfort after eating, heartburn, nausea, vomiting, pale stools
3. Cardiovascular: Decreased blood pressure, lightheadedness, fainting
4. Bone Marrow: Anemia, bone pain, fractures.
5. Respiratory: Wheezing, shortness of breath, coughing
6. Neurologic: Headache, tremors, numbness
7. Lymphatic: Swelling of lymph nodes, liver, spleen and other organs


A number of factors can trigger symptoms of mast cell disorders:
1. Physical: Heat, cold, friction, sunlight, fever, fatigue, physical exertion
2. Emotional stress
3. Food: Cheese, spices, shellfish, food preservatives (e.g., MSG), food additives (e.g., flavorings, colorings)
4. Infections: Bacteria, viruses, fungi
5. Drugs: Aspirin, antibiotics, anesthetics, opioids, alcohol
6. Insect bites or stings
7. Irritants: Strong odors, perfumes, other chemical irritants
8. Surgery


1. Blood tests: Measure tryptase levels at the baseline (i.e., before flare-up) and during a flare-up when tryptase levels are more likely to be elevated.
2. Urine tests: Measure the metabolic end products of tryptase
3. Bone marrow biopsy: Microscopic examination of the bone marrow for evidence of mast cell deposition
4. Skin biopsy: Microscopic examination of skin lesions
5. Genetic tests: Looks for gene abnormalities
6. Chest and bone X-rays or scans
7. Skin prick tests: Detects specific IgE antibodies to environmental and/or food allergens, if suggested by history of flare-ups on exposure


Unfortunately, there is no cure for these disorders but various manifestations can be treated in order to help relieve the symptoms as well as help preserve the function of organs systems.

1. Acute severe systemic reactions (i.e., anaphylaxis) are treated with an immediate epinephrine injection. Patients should to carry an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) and wear a medical alert bracelet. If used, it is important for the individual to go to the closest emergency room.
2. Itching, flushing, and other skin allergy symptoms can be controlled by using H1-blocking antihistamines such as Claritin (loratadine), Allegra (fexofenadine), and Zyrtec (cetirizine) in combination with H2-blockers such as Tagamet (cimetidine) or Pepcid (famotidine).
3. Medications which stabilize the mast cells such as cromolyn, nedocromil, and ketotifen can help prevent from degranulation of the granules inside mast cells and thus help prevent the release of chemical mediators into the tissues and the bloodstream. These medications are often used to treat gastrointestinal symptoms such as nausea, vomiting, and abdominal cramping.
4. Digestive symptoms caused by mast cell disorders can also be improved with proton pump inhibitor (PPI) medications such as Prilosec (omeprazole), Prevacid (lansoprazole), and Nexium (esomeprazole).
5. Albuterol inhalers will help open the airways and help wheezing, coughing and/or shortness of breath in individuals with respiratory symptoms.
6. Anticholinergic medications may be used to reduce the motility of the bowels which may help control diarrhea.
7. Anti-inflammatory medications such as corticosteroids (e.g., prednisone) and leukotriene antagonists [e.g., Singulair (montelukast), Accolate (zafirlukast), Zyflo (zileuton)] are sometimes used to help control systemic symptoms. Topical corticosteroid creams or ointments, as well as phototherapy can improve localized skin lesions.
8. Surgical removal of the spleen can help improve severe symptoms in some individuals.
9. Immune modulating medications such as interferons may be used in more severe cases of systemic mastocytosis
10. Bone marrow transplant may be necessary in severe cases of systemic mastocytosis.
11. Stem cell therapy may be necessary in severe cases of systemic mastocytosis.


Most cases of localized mast cell disease can persist for many years as nodules on the skin. In rare instances, cancers can develop which require constant monitoring.

Systemic mastocytosis tends to be persistent at a low level for decades, requiring treatment to control symptoms. Occasionally, however, it can become aggressive and even life-threatening.

Avoidance of exposure to the known triggers, as best as possible, can help minimize the symptoms and reduce the need for medications.

The board certified allergy specialists at Black & Kletz Allergy treat both adult and pediatric patients. We have been diagnosing and treating mast cell diseases for many years. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices have on-site parking. In addition, the Washington, DC and McLean, VA offices are Metro accessible and the McLean, VA office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line. To schedule an appointment, please click Request an Appointment and we will respond within 24 hours by the next business day. The allergists at Black & Kletz Allergy have been the trusted allergists in the greater Washington, DC and Northern Virginia community for over 50 years. We pride ourselves for our outstanding services we provide for the diagnosis and treatment of mast cell disorders as well as other conditions in the fields of allergy, asthma, and immunology.

Spring Cold or Spring Allergies?

Spring is in the air and many individuals are suffering. Although many are experiencing the signs and symptoms of hay fever (i.e., allergic rhinitis), not all of these individuals are allergic to the Spring pollens. In a typical Spring hay fever patient, the symptoms are generally due to an allergy to either tree pollen, grass pollen, or molds. In some individuals however, they may still exhibit the same annoying symptoms as an allergic person, but when skin tested by a board certified allergist, they are negative. In these individuals, they are irritated by pollens or molds as opposed to being allergic to them. This condition is called nonallergic rhinitis or vasomotor rhinitis. For the sufferer, it does not much matter because they may feel awful, but from a treatment standpoint, it does matter because some of the medications used to treat allergic individuals will not help alleviate the nonallergic irritant effects caused by these particles. Still further, there are people who have a viral infection such as the common cold who exhibit many of the same symptoms as an allergic individual, but should again be treated differently from the previous 2 groups mentioned above.

Since the signs and symptoms of the 3 conditions (i.e., allergic rhinitis, nonallergic rhinitis, common cold) may be very similar and overlap, it is important for the allergist to distinguish them in order to manage them more effectively.

The classic symptoms of hay fever or allergic rhinitis may include sneezing, itchy nose, runny nose, nasal congestion, post-nasal drip, itchy throat, itchy eyes, watery eyes, redness of the eyes, and/or puffy eyes. Some individuals will also experience sinus congestion, sinus headaches, snoring, and/or fatigue. Fever and/or chills is not usually present despite the name “hay fever.”

The typical symptoms of nonallergic rhinitis is similar to that of allergic rhinitis although the itchiness is usually not present. Thus, the symptoms are typically sneezing, runny nose, post-nasal drip, and/or nasal congestion. Some patients may also complain of sinus headaches and/or sinus congestion. Ocular symptoms may include watery eyes and/or redness of the eyes.

The common cold is caused by an infection with a virus. The symptoms of a “cold” are similar to those of nonallergic rhinitis although, in addition, fever, chills, and/or muscle aches may also be present. Eye symptoms and itchiness is generally not a feature of the common cold. The length of time of the discomfort is usually far less than that of patients with either allergic rhinitis or nonallergic rhinitis, since viruses are usually self-limited and the average length of time of a “cold” is generally less than 7 days. The symptoms of allergic rhinitis or nonallergic rhinitis in the Spring may last the entire pollen season which may be up to 4-5 months in duration. Of course, many individuals may be allergic to other allergens such as weeds, dust mites, and/or pet dander which can complicate the matter and cause the person to experience symptoms at other times of the year or have perennial symptoms.

The treatment of the 3 conditions is different and it is thus important to know which malady is present in an individual. The management of allergic rhinitis may include antihistamines, decongestants, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, leukotriene antagonists, ocular antihistamines, ocular mast cell stabilizers, ocular nonsteroidal anti-inflammatory agents (NSAIDs), and/or ocular corticosteroids. Allergy immunotherapy (i.e., allergy shots, allergy desensitization, allergy hyposensitization) is very efficacious in the treatment of allergic rhinitis as it helps in 80-85% of individuals who take it. Allergy shots, on the other hand, are not prescribed in patients with nonallergic rhinitis or the common cold.

The treatment of nonallergic rhinits is similar to the management of allergic rhinitis however, nasal corticosteroids are the primary method of treating this condition. It is unnecessary to use leukotriene antagonists and less important to use oral, nasal, and ocular antihistamines. As mentioned above, allergy immunotherapy is not used to treat nonallergic rhinitis.

The management of the common cold is based on treating the symptoms only as viruses are self-limiting and the symptoms of the common cold will generally disappear within 7 days of the onset of the cold. The treatment is similar to that of nonallergic rhinitis with the exception of the use of eye drops since patients with the common cold do not generally exhibit ocular symptoms. In addition, the use of acetaminophen (i.e., Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen) may be desired in order to help alleviate associated fevers, chills, and/or muscle aches.

The board certified allergists at Black and Kletz Allergy have over 50 years of experience in diagnosing and treating allergic rhinitis, nonallergic rhinitis, and the common cold. We treat both adult and pediatric patients. Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. To make an appointment, please call any one of our offices directly or you may click Request an Appointment and we will respond within 24 hours by the next business day. The allergists at Black & Kletz Allergy have been servicing the greater Washington, DC metropolitan area for more than 5 decades and we look forward to providing you with the best state-of-the-art allergy care in a pleasant and hospitable environment.

Pancake Syndrome (Oral Mite Anaphylaxis)

Dust mites are one of the most common triggers of allergic conditions such as in the conditions of hay fever (i.e., allergic rhinitis), allergic asthma, atopic dermatitis (i.e., eczema), and/or food allergies. Dust mites are microscopic insects that live in house dust and on human skin scales. The allergens are excreted in their droppings which then become aerosolized. When sensitized individuals are exposed to these substances in the air, they develop bothersome allergy symptoms such as nasal congestion, runny nose, sneezing, post-nasal drip, itchy nose, itchy eyes, watery eyes, redness of the eyes, fatigue, sinus pressure, sinus headaches, chest tightness, coughing, wheezing and/or shortness of breath.

Although uncommon, some individuals who are sensitive to mites can also develop severe allergic symptoms immediately after eating foods prepared with wheat flour contaminated with various species of mites. This syndrome is designated as oral mite anaphylaxis (OMA) or “pancake syndrome.” It is called pancake syndrome because the most common food to cause such a severe allergic reaction are pancakes.

This condition is more commonly reported from tropical and subtropical regions, probably because in those regions there are environmental conditions favorable for mite reproduction, especially higher temperatures and relative humidities, for longer periods of time. The majority of subjects are adolescents and young adults, although oral mite anaphylaxis can occur in children. In most cases, there is a previous history of atopy where individuals have a history of allergic rhinitis, asthma, atopic dermatitis, and/or food allergies. The allergic individual tends to develop symptoms between 10 minutes and 4 hours after eating the mite-infested food.

The types of mites identified in the pancake syndrome are generally either dust mites or storage mites. The most common dust mites are Dermatophagoides farinae and Dermatophagoides pteronyssinus. The most common storage mites include Blomia tropicalis, Blomia freeman, and Suidasia pontifica, Aleuroglyphus ovatus, Thyreophagus entomophagus, Lepidoglyphus destructor, and Tyrophagus putrescentiae.

The typical symptoms of the pancake syndrome may include shortness of breath, laryngeal and/or facial angioedema (swelling of the vocal cords and/or face which may result in a blocked airway), wheezing, coughing, runny nose, difficulty swallowing, urticaria (i.e., hives), abdominal cramping, and/or redness of the eyes. The clinical presentation may be very severe, such as anaphylaxis, which can lead to hospitalization in the intensive care unit due to laryngeal edema and acute respiratory failure.

Implicated foods usually contain wheat flour, and may include foods such as pancakes, bread, pasta, and pizza. As mentioned previously, pancakes are the most frequently involved food. It is important to note that the allergens causing oral mite anaphylaxis are resistant to heat. Thus, the reactions to the mite-contaminated foods can be induced by well-cooked foods. This is different than what is seen in oral allergy syndrome (i.e., pollen food allergy syndrome). In oral allergy syndrome, well-cooked foods denature the allergen, so individuals can eat well-cooked fresh fruits and/or vegetables without symptoms. In oral mite anaphylaxis, individuals will still develop symptoms even if the mite-infested food is well-cooked. Of note, allergy skin tests with mite-contaminated wheat flour, both before and after it is cooked, will also be positive.

In addition to oral mite anaphylaxis being more common in dust mite sensitive individuals with allergic rhinitis, asthma, atopic dermatitis and/or food allergies, it is also more commonly seen in patients with aspirin and/or NSAID (i.e., nonsteroidal ant-inflammatory drug) hypersensitivity. These patients generally develop hives and/or swelling when they consume aspirin or NSAIDs. Genetic factors are thought to be responsible for this association.

There is also a variant of oral mite anaphylaxis which only occurs after eating mite-infested food followed shortly thereafter by exercise. If the person does not exercise, no symptoms occur. If the person only eats the mite-contaminated food, no symptoms occur. It is the consumption of the mite-contaminated food followed by exercise within a relatively short period of time that will cause the allergic symptoms we have been referring to throughout this blog. This variant of the pancake syndrome has been named dust mite ingestion-associated exercise-induced anaphylaxis.

Risk Factors for Oral Mite Anaphylaxis:
1. Mite allergy
2. History of atopic disease (i.e., allergic rhinitis, asthma, atopic dermatitis)
3. Aspirin/NSAIDs hypersensitivity (i.e., hives/swelling from aspirin/NSAIDs)
4. Consumption of foods prepared with mite-contaminated wheat flour
5. Consumption of more than 1 mg. of mite allergen (>500 mites/gram of flour)

Diagnosis of Oral Mite Anaphylaxis:
1. Previous history of rhinitis, asthma, atopic dermatitis, and/or food allergies
2. Allergic symptoms occur after eating foods prepared with wheat flour
3. Positive skin test with the suspected flour
4. Negative skin tests to wheat and to uncontaminated flour
5. Mite allergens present in flour
6. Identification of mites via a microscope in suspected flour
7. Ability to eat uncontaminated flour without symptoms
8. Aspirin/NSAIDs hypersensitivity in some patients
9. Exercise-induced anaphylaxis with mite-contaminated food in some patients

It is known that mites can grow in closed packages of wheat flour at room temperature. It is also known that exposure to low temperatures inhibits mite proliferation. In order to try to prevent oral mite anaphylaxis, is recommended to store flour in sealed containers in the refrigerator.

The board certified allergy specialists at Black & Kletz Allergy have been treating mite allergies in children and adults in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than half a century. Black & Kletz Allergy provides on-site parking at all of their convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The Washington, DC and McLean, VA locations are Metro accessible and there is a complementary shuttle that runs between our McLean office and the Spring Hill metro station on the silver line. Please call any of our offices to schedule an appointment for your allergy, asthma, or immunology needs. Alternatively, please click Request an Appointment and we will respond within 24 hours on the next business day. We strive to provide our patients with the highest quality and most up-to-date allergy diagnostic tests and treatments in a pleasant, caring, and professional environment.