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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

Prevention:
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.

Hay Fever in the Spring

Later this month, Spring is officially here. Along with the warmer weather and longer days comes the pollination of trees and grasses. For some allergy sufferers, the presence of tree and grass pollens can be a miserable sight as these pollens may cause an array of allergy and asthma symptoms that are very annoying.

The allergic reaction to the pollen in the Spring is known as hay fever. The technical term however is called allergic rhinitis. The classic symptoms of hay fever (allergic rhinitis) may include nasal congestion, sneezing, runny nose, post-nasal drip, itchy nose, sinus congestion, itchy throat, sinus headaches, snoring, and/or fatigue. Individuals with allergic rhinitis are also more prone to sinus infections (i.e., sinusitis). It is caused by the inflammation of the inside of the nose. There are other allergens that may also cause allergic rhinitis and some of them may include dust mites, other pollens (e.g., weeds), molds, animal dander/urine/saliva (i.e., cat, dog, hamster), and/or cockroach. Allergic rhinitis can be classified into 2 groups: seasonal allergic rhinitis and perennial allergic rhinitis. Seasonal allergic rhinitis is a condition where an allergic patient experiences symptoms of allergic rhinitis during a particular season. It is usually attributable to a pollen allergy as pollen levels generally fluctuate depending on the season. It should be noted however that molds are also a common allergen that will cause allergic rhinitis. Although any season is possible, the most common season(s) are either Spring or Fall or a combination of both Spring and Fall. Tree pollen in the Washington, DC, Northern Virginia, and Maryland metropolitan area usually begins to pollinate in mid-February and continues until late-May. Grasses typically pollinate in the DC area from early May through the end of July. Perennial allergic rhinitis is a condition where an allergy patient can suffer throughout the year. It is typically dust mites, molds, pets, and/or cockroaches that are the cause of the perennial nature of this disease.

In addition to nasal symptoms, many individuals also suffer or only suffer from eye symptoms due to the tree or grass pollens. Molds may also play a role in some individuals. These patients are also said to have hay fever, but in this case, the technical term is called allergic conjunctivitis. The classic symptoms of allergic conjunctivitis may include itchy eyes, watery eyes, puffy eyes, burning eyes, and/or redness of the eyes. It is caused by inflammation of the thin layer of tissue (i.e., membrane) that covers the inside of the eyelids and eyeball. This thin membrane is called the conjunctiva. Some other allergens that may cause allergic conjunctivitis may include dust mites, molds, other pollens (e.g., weeds), cockroach, animal dander/urine/saliva (i.e., cat, dog, hamster), cosmetics, perfumes, eye drops, and/or dermatologic medications.

Asthma is an inflammatory condition of the airways of the lungs. In addition to inflammation, asthma is also associated with narrowing of the airways and increased mucus secretion into the airways. Asthma can be caused or triggered by numerous factors such as allergens (e.g., pollens, molds, dust mites, cockroach, pets), irritants, viruses [e.g., respiratory syncytial virus (RSV), rhinovirus], exercise, cold air, food additives (e.g., sulfites), gastroesophageal reflux disease (GERD), certain medications (e.g., beta-blockers, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or aspirin. In the Spring, the pollens as well as molds can trigger asthma in sensitized individuals.

The diagnosis and treatment of allergic rhinitis, allergic conjunctivitis, and/or asthma are routinely performed by the board certified allergists at Black & Kletz Allergy at any one of our 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area. After a comprehensive history and physical examination, allergy testing may be performed by either skin testing or blood testing. If one has asthma or has symptoms of asthma (i.e., wheezing, coughing, chest tightness, or shortness of breath), a pulmonary function test may be performed as well. Depending on the results, a variety of medications may be prescribed which may include antihistamines, decongestants, nasal sprays, leukotriene antagonists, eye drops, and/or asthma inhalers. Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization) may be recommended as it is a very effective tool to combat allergic rhinitis, allergic conjunctivitis, and/or asthma. It is efficacious in 80-85% of patients who go on allergy shots. Allergy injections have been given in the U.S. for more than 100 years and are used in both children and adults.

If you would like to schedule an appointment with one of our board certified allergy doctors, please call one of our offices. The offices of Black & Kletz Allergy are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices offer on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean, VA office location offers a complementary shuttle that runs between this office and the Spring Hill metro station on the silver line. In lieu of calling one of our offices, 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 diagnosing and treating allergic rhinitis, allergic conjunctivitis, and asthma for more than 50 years in the Washington, DC area and we pride ourselves in providing state-of-the-art allergy, asthma, and immunology care in a relaxed and professional environment.

Oral Allergy Syndrome

Oral allergy syndrome (also known as pollen food allergy syndrome) affects approximately one third of people with seasonal allergic rhinitis (i.e., hay fever).

The symptoms of seasonal allergic rhinitis may include nasal congestion, runny nose, itchy nose, sneezing, itchy eyes, watery eyes, and/or red eyes during tree, grass and/or weed pollinating seasons. In our geographical area, the trees and grasses pollinate mostly in Spring and early Summer and the weeds, especially ragweed, pollinate in the Fall. It is common for these individuals to experience the symptoms during those seasons. The underlying mechanism of oral allergy syndrome is a genetically determined “sensitization” of the immune system to various pollens and subsequent “reactions” when exposed to these pollens. The immune system considers these pollens as “foreign” and thus reacts against them resulting in the annoying symptoms of hay fever.

A number of individuals with pollen allergies will experience a situation where they will develop itching of the lips, gums, tongue, palate and/or throat after eating raw fresh fruits and/or vegetables. This condition is termed pollen food allergy syndrome or oral allergy syndrome. This occurs because of the similarity of the protein antigens in the pollen and the protein antigens of the fresh fruits and/or vegetables. The immune system which is previously sensitized to pollen will also react to the similarly structured proteins in the fruits and/or vegetables. This phenomenon is termed cross-reactivity. Thus when an individual who has a pollen allergy eats certain raw fresh fruits and/or vegetables, the person’s immune system “thinks” that they are being exposed to pollen proteins when in fact they are being exposed to fruit/vegetable proteins that have a very similar structure to the pollen proteins. The body in turn reacts to the fruit/vegetable proteins in a similar fashion as a typical allergic reaction but is usually more localized to where the food makes direct contact, such as the lips, gums, tongue, palate, and/or throat.

This condition tends to be more prominent and bothersome in the Spring months when we are exposed to higher levels of pollen. Specific tree pollen sensitivity cross-reacts with specific fruit/vegetable proteins due to the closeness in the amino acid sequences. For example, patients with birch pollen sensitivity tend to react more commonly with fresh raw pitted fruits (e.g., peaches, apricots, plums), apples, and/or carrots. Birch pollen allergy can also cross-react with peanuts and/or tree nuts.

Individuals with allergies to grasses may have a reaction to peaches, celery, tomatoes, melons (e.g., cantaloupe, watermelon, honeydew), and oranges. Ragweed pollen sensitivity in the Fall usually cross-reacts with melons, bananas, zucchini, and/or cucumbers.

The symptoms usually begin within a few minutes after eating the raw fresh fruits and/or vegetables and generally subside within a few hours. The symptoms of oral allergy syndrome typically include itching of the lips, mouth, and/or throat as mentioned above. The symptoms are usually mild, but in rare cases, can cause throat swelling and/or difficulty in swallowing. Such severe reactions are more likely to happen with peanuts and/or tree nuts. It is important to note that some people with itchy lips, mouth and/or throat after eating a raw fresh specific fruit and/or vegetable may in fact have a true food allergy to a specific fruit and/or vegetable and not have oral allergy syndrome. These truly food-allergic individuals generally will have the same or similar symptoms even when eating the fruit/vegetable cooked, unlike patients with oral allergy syndrome who can generally tolerate the cooked fruit/vegetable without symptoms.

The diagnosis is established mostly by a history of oral pruritus (i.e., itching) and irritation in patients who have previously tested positive to pollen and are symptomatic during the respective pollen seasons.

The treatment of oral allergy syndrome involves avoiding the offending raw fresh fruits/vegetables. Peeling the skin before eating and/or cooking (i.e., baking, microwaving) before eating may decrease the severity of the symptoms, as heat denatures the protein and reduces its allergenic potential.

Below is a chart from the American Academy of Allergy, Asthma & Immunology of different types of pollens and the corresponding foods that may cause oral allergy syndrome:

SPRING               SUMMER                LATE SUMMER – FALL               FALL

Pitted Fruit
Apple                         X
Apricot                      X
Cherry                       X
Peach                         X                               X
Pear                            X
Plum                          X

Melons
Cantaloupe                                                                                                 X
Honeydew                                                                                                   X
Watermelon                                                X                                             X

Other
Banana                                                                                                         X
Kiwi                            X
Orange                                                         X
Tomato                                                        X

Vegetables
Bell pepper                                                                                                                                           X
Broccoli                                                                                                                                                 X
Cabbage                                                                                                                                                X
Carrot                         X
Cauliflower                                                                                                                                           X
Celery                          X
Chard                                                                                                                                                     X
Cucumber                                                                                                    X
Garlic                                                                                                                                                     X
Onion                                                                                                                                                     X
Parsley                        X                                                                                                                        X
White potato                                                X                                           X
Zucchini                                                                                                      X

Spices
Aniseed                                                                                                                                                  X
Caraway                                                                                                                                                 X
Coriander                                                                                                                                              X
Fennel                                                                                                                                                    X
Black pepper                                                                                                                                         X

Legumes*
Peanut                       X
Soybean                    X

Nuts*
Almond                     X
Hazelnut                   X

*Mouth or throat itching from peanut, soybean, almonds, and hazelnuts may also be an initial
manifestation of a more serious food allergy with the potential for anaphylaxis. See an
allergist/immunologist if such symptoms are noted.

© 2019 American Academy of Allergy, Asthma & Immunology.

 

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating oral allergy syndrome and food allergies 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 offices have on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. To schedule 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 an itchy mouth or throat after eating fruits and/or vegetables or you have other food allergy symptoms, we are here to help diagnose and treat your food allergy. The allergists at Black & Kletz Allergy are happy to help you with any allergic condition that you may have as we are dedicated to providing you with the highest quality allergy care in a relaxed, caring, and professional environment.

Bug Bite and Sting Allergies and Reactions

Bug bites are certainly very common. Almost everyone has been bitten by a bug in their lifetime and almost everyone has had at least a minor local reaction to the bug bite. In some instances, an individual may have a more severe reaction that is not an allergic reaction but it can mimic an allergic reaction. In other cases, however, an individual may actually have a true allergic reaction. In order to differentiate between an allergic reaction and a non-allergic reaction, a consultation with a board certified allergist may be necessary.

There are 4 basic types of reactions that may occur from a bug bite. They are classified as follows:

  • Local irritant reaction
  • Allergic reaction
  • Toxic reaction
  • Serum sickness reaction

The first two reactions are by far the most common. Overwhelmingly, a local irritant reaction is the most common of the four reactions. The symptoms of a local irritant reaction may include local redness, pain, itching, and/or swelling. It is generally self-limited and usually resolves on its own without treatment. If treatment is desired, one can use over-the-counter (OTC) antihistamines or OTC topical corticosteroids to treat this type of reaction.

An allergic reaction to a bug bite is not very common, however they do occur. Symptoms can mimic a local irritant reaction but the reaction may be more severe. Additional symptoms may include blistering of the skin, generalized itching of the skin, throat closing sensation, hives (i.e., urticaria), warm feeling, increased heart rate, drop in blood pressure, lightheadedness, dizziness, fainting, wheezing, and/or shortness of breath. It is more common to have true allergic reactions to the venom of stinging insects such as honey bees, yellow jackets, hornets, wasps, and fire ants. The treatment of an allergic reaction to a bug bite is aimed at treating and controlling the symptoms. OTC antihistamines and/or OTC topical corticosteroids are generally adequate enough in to treat this condition. Occasionally, prescription medications such as more potent antihistamines, histamine2-blockers (e.g., Pepcid, Tagamet), leukotriene antagonists (e.g., Singulair), and/or oral corticosteroids may be necessary in order to treat the allergic reaction. Rarely, the use of asthma inhalers (e.g., albuterol) may be necessary in individuals who develop symptoms of asthma which may include shortness of breath, chest tightness, coughing, and/or wheezing. An individual who has had a systemic allergic reaction to a stinging insect (e.g., honey bees, yellow jackets, hornets, wasps, fire ants) should be skin tested by a board certified allergist. If that individual reacts to the venom skin testing, it is strongly recommended that this person go on a course of venom immunotherapy (i.e., allergy shots for stinging insects) as they are very efficacious in preventing anaphylaxis. It is very important that such an individual carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) in case they are stung, as insect sting allergies can be fatal. If the epinephrine device is used, it is imperative that the patient go immediately to the closest emergency room. It also should be known that honey bees leave their stingers in their victims and if stung by a honey bee, never pull out the stinger. Instead, one should scrape off the stinger. Pulling out a stinger may cause the pinching of the venom sac, which may in turn cause the venom sac to introduce more venom into the affected person.

A toxic reaction to bug bites or stings occurs when a bug introduces various substances into an individual such as a toxin or venom. Assuming there is not an allergic reaction to the venom, as mentioned above, the venom may act as a poison and cause direct harm to the tissues of the individual. Toxic reactions can occur from one sting or bite from a highly toxic insect or spider, or from multiple stings or bites from insects or spiders not normally considered poisonous. The symptoms of a toxic reaction may include nausea, vomiting, fever, fainting, lightheadedness, pain or redness or swelling at the site of the sting or bite, headache, muscle spasms, seizures, and/or shock. It is even potentially fatal. The treatment of a toxic reaction to bug bites or stings is primarily based on supportive care. Antihistamines and corticosteroids may be used. In addition, standard wound care precautions and treatment should be utilized as it is not uncommon for the site of the bite or sting to become infected. Antibiotics should be used when needed.

The fourth type of reaction that can occur due to a bug bite or sting is serum sickness. Serum sickness can occur as a result of a reaction towards the venom of either insect stings or spider bites. The symptoms generally manifest hours to days after the sting or bite. The classic symptoms may include fever, joint pain, itching, rash or hives, and/or fatigue. Other symptoms may include swollen lymph nodes, enlarged spleen, drop in blood pressure, and/or shock. In addition to venom, medications (e.g., penicillins, cephalosporins, allopurinol), blood products (e.g., transfusions), and antitoxins (e.g., antivenom) have been known to rarely cause serum sickness. The treatment of serum sickness usually entails antihistamines, corticosteroid creams, and/or nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, naproxen). In severe cases, oral corticosteroids are often utilized.

If you or someone you know have experienced an insect sting or bug bite and had more than a minor reaction, the board certified allergists at Black & Kletz Allergy are here to help. We diagnose and treat both adults and children in all facets of allergy, asthma, and immunology. We often see patients for consultations about insect stings and bug bites. Our allergists will perform venom testing on those individuals who meet the requirement for testing. In addition, a specific plan for future stings and/or bites will be discussed with the patient in order to reduce the individual’s fear and confusion regarding reactions to the bite and/or sting. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 of our offices have on-site parking.  For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line.  For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment as we have done for over 50 years.

Penicillin Allergy

Penicillin allergy is reported in roughly 7-10% of the general population and in up to 20% of hospitalized patients. Even though the reported numbers are fairly high, approximately 90% of these reported cases do not actually have a penicillin allergy. Individuals think they are allergic, but in most cases, the symptoms that they experience are either a non-allergic side effect or completely unrelated to penicillin. An allergy to penicillin, however, appears to be the most common medication allergy, along with other antibiotics.

Penicillin is comparatively inexpensive while being very efficacious. This make it both a common as well as a good choice for clinicians to use when an antibiotic is necessary. For those who have a true allergy to penicillin, the penicillin is seen as a foreign “invader” and one’s immune system mounts a defensive response in order to try to subdue the “invader.” When the immune system mounts a response, chemical mediators are released into the bloodstream in order to attack the intruder. As a result of these chemical mediators (e.g., histamine, leukotrienes), the individual may experience itching, hives, and/or swelling. In severe cases, an anaphylactic reaction may occur where individuals may develop wheezing, shortness of breath, rapid heartbeat, and/or drop in blood pressure.

Most people with a probable history of penicillin allergy are given alternative antibiotics in order to treat infections.  In most cases, the replacement antibiotic will be more expensive than penicillin. It also may not be as effective as penicillin. In addition, the use of a replacement antibiotic can result in bacteria developing resistance to these alternative antibiotics, which will be a detriment to the community as a whole.  In the field of allergy and immunology, is important to distinguish between a “false” allergy and a “true” allergy to penicillin and related antibiotics, so that the correct and appropriate antibiotic can be utilized. The evaluation of penicillin allergy requires the use of a standardized penicillin testing protocol. At Black & Kletz Allergy, our board certified allergists routinely perform this procedure in our office. Skin testing has been used for the diagnosis and management of penicillin allergy since the 1960’s.  The procedure is commonly performed with minimal risk.  Penicillin skin testing can be done safely in properly selected patients with suspected penicillin allergy.

The procedure for penicillin skin testing involves 3 steps:

  • Skin prick testing with a small amount of diluted penicillin allergens, negative control solution, and positive control solution.
  • If the prick tests are negative after 20 minutes, intradermal skin testing is performed where a very small quantity of the allergen, negative control solution, and positive control solution is injected into the superficial layers of the skin.
  • If the intradermal skin test in in this second stage is also negative after 20 minutes, the patient will be given 250 mg. of amoxicillin by mouth (i.e., oral challenge) and will be closely monitored for 90 minutes.

If the patient tolerates all 3 stages without any untoward effects, the patient may receive penicillin if needed without an increased risk of an immediate allergic reaction than that of the general population. Penicillin testing should only be performed in a healthcare setting only by an allergist with the knowledge, training, and experience to select appropriate patients for this procedure, interpret the test results, and manage a systemic allergic reaction if it were to occur. This procedure can accurately identify the roughly 9 of 10 patients, who despite reporting a history of penicillin allergy, can receive penicillin safely. It should be noted that most individuals who say that they are allergic to penicillin because “they were told they had a reaction as a young child” turn out not to have a penicillin allergy when tested by a board certified allergist. It is however important to be tested and to not just assume you will be negative. All presumed “penicillin-allergic” individuals should continue to avoid penicillin until they are tested by an allergist.

The board certified allergists at Black & Kletz Allergy have been diagnosing and managing penicillin allergy, as well as other medication allergies 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 offices have on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. For an appointment, please call our office or alternatively, yo

hand with pen drawing the chemical formula of Penecillin

u can click Request an Appointment and we will respond within 24 hours by the next business day. If you have a penicillin allergy or think you have a penicillin allergy, we are here to help you by testing you to see if you are allergic to penicillin. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, caring, and professional environment.

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.

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.

Cold Allergies

As we enter into the Winter months, a sensitivity to cold temperatures may trigger some allergic reactions in susceptible individuals. Below are some conditions where exposure to cold can cause clinical disease.

Cold-Induced Urticaria:

Exposure of the skin to cold temperatures can be a trigger for breaking out in hives. Cold-induced hives (i.e., urticaria) typically manifest themselves as intensely itchy, red raised blotches (i.e., welts) of various shapes and sizes over the exposed skin. The hives usually begin to develop within 5 to 10 minutes after the exposure to cold, usually when the skin is rewarming. This condition (i.e., cold-induced urticaria) is usually noticed after returning indoors from cold temperatures outdoors or after swimming and coming out of a cold water pool. The hives generally last for about 1 to 2 hours.

More severe cases of cold sensitivity may also result in anaphylaxis, a life-threatening condition in which in addition to hives one may also experience systemic symptoms such as nausea, dizziness, difficulty in breathing, and/or fainting. This condition is referred to as cold-induced anaphylaxis. Certain viral infections are thought to play a role in the etiology of this disorder.

The diagnosis of cold-induced urticaria or cold-induced anaphylaxis entails comprehensive history taking, a physical examination, and an “ice cube test.” This involves placing an ice cube in a plastic bag over the skin and keeping it in place for approximately 10 minutes before removing it. As the skin rewarms, an itchy, red, welt appears on the skin in the shape of the ice cube with slightly raised edges. A positive ice cube test confirms the diagnosis of cold-induced urticaria.

Treatment of this condition involves avoidance of the exposure to cold temperatures at all times. Bundling up before venturing out into cold weather and checking the temperature of water before swimming are helpful in preventing acute episodes. Avoidance of drinking cold beverages may also be helpful in certain patients.

When avoidance to the exposure of cold is not possible or practical, taking antihistamines can minimize the severity of symptoms. Periactin (i.e., cyproheptadine) is a first generation antihistamine that has been proven to be beneficial in this condition.

A recent study in 2019 found that a “biologic” medication named Xolair (i.e., omalizumab) was also effective in preventing cold-induced hives when taken as a subcutaneous injection every 4 weeks.

Individuals with a history of cold-induced anaphylaxis should be trained in the proper technique of using an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) and carry it at all times. It is available at most pharmacies in various brand names and requires a prescription from a physician. It should be noted that an individual should go to the nearest emergency room immediately if the self-injectable epinephrine device was used.

Many patients with cold-induced urticaria notice that their symptoms usually become less frequent and less severe after 5 to 10 years.

Familial Cold Autoinflammatory Syndrome:

Familial cold autoinflammatory syndrome (FCAS), also known as familial cold urticaria, is a rare, inherited inflammatory disorder characterized by occasional episodes of rash, fever, joint pain, and/or other signs or symptoms of systemic inflammation triggered by the exposure to cold. The onset of FCAS occurs during infancy and early childhood and persists throughout the patient’s life.

Other symptoms may include profuse sweating, drowsiness, headache, extreme thirst, red eyes, blurred vision, eye pain, watering eyes, nausea and/or vomiting.

Symptoms typically occur within hours after exposure to cold. In most cases, a rash will occur within the first 1-2 hours, followed by a fever and joint pain. Episodes usually last for less than 24 hours.

The treatment of familial cold autoinflammatory syndrome may include non-steroidal anti-inflammatory drugs (NSAIDs) which are often used to alleviate joint pain. High doses of corticosteroids have shown to be somewhat effective, but may cause short and long-term side effects.

Chilblains:

Chilblains is a vascular condition in which the very small blood vessels become inflamed when exposed to cold air. Symptoms may include red skin, itching, pain, blistering, and/or swelling. These symptoms usually resolve within a few weeks, especially if the weather gets warmer.

Raynaud’s Disease/Phenomenon:

Raynaud’s disease primarily affects the fingers and toes. It usually occurs when an individual is exposed to the cold. Individuals with this condition have blood vessel constriction that causes an interruption in the flow of blood to their extremities.

Symptoms may include pain and paleness or blueness of the skin in the affected areas following exposure to cold temperatures. Symptoms may last minutes or hours. This disorder may be associated with other underlying conditions such as connective tissue disorders (e.g., rheumatoid arthritis, systemic lupus erythematosus), smoking, certain medications (e.g., high blood pressure medications, ADHD medications, hormones), certain foods (e.g., caffeine), and carpal tunnel syndrome. If no associated underlying condition is found, it is referred to as Raynaud’s phenomenon.

Cold Agglutinin Disease:

In individuals with cold agglutinin disease, the body attacks its red blood cells in response to their blood temperature falling to a lower temperature than their regular body temperature.

This condition can result in hemolytic anemia (i.e., a disorder where one’s red blood cells are destroyed faster than they are made). It’s often associated with mycoplasma pneumonia infection, scarlet fever, staphylococcal infections, and rheumatological conditions.

Paroxysmal Cold Hemoglobinuria:

Paroxysmal cold hemoglobinuria is a rare autoimmune disorder usually seen in children in response to cold exposure after an infection. It mainly affects the hands and feet. The symptoms may include dark brown colored urine (due to blood pigment), fever, anemia, abdominal pain, and difficulty in breathing. The condition has been linked to secondary syphilis, tertiary syphilis, and other viral or bacterial infections.

The board certified allergists at Black & Kletz Allergy located in the Washington, DC, Northern Virginia, and Maryland metropolitan area will readily answer any questions you have regarding your hives (i.e., urticarial), allergies, and/or asthma.  We have 3 offices with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer on-site parking.  In addition, the Washington, DC and McLean, VA offices are accessible by Metro.  We also have a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  Please make an appointment by calling any one of our 3 offices, or alternatively, you can click Request an Appointment and we will answer you within 24 hours by the next business day.  Black & Kletz Allergy diagnoses and treats both children and adults and we are proud to serve the Washington, DC metro area, which we have done for more than 5 decades.