Update on Alpha-Gal Syndrome

January 16, 2026 | Black & Kletz Allergy

Alpha-gal syndrome is an allergic condition caused by a sensitivity to a carbohydrate known as galactose-alpha-1,3-galactose (i.e., alpha-gal).  This molecule is found on the cells of non-primate mammals (i.e., beef, pork, lamb, venison, etc.).  This condition is mainly thought to develop after tick bites.  The regional distribution of alpha-gal syndrome corresponds with specific tick species populations (e.g., the lone star tick).  Alpha-gal syndrome is also called mammalian meat allergy. In the United States, the prevalence of lone start ticks and alpha-gal syndrome is highest in the Southeast region.  Overall, the prevalence of alpha-gal syndrome is thought to be rising, with current estimates suggesting that up to 450,000 cases have occurred in the U.S. since 2010.  It was first diagnosed in Virginia. Other organisms besides ticks have been implicated in the potential induction of alpha-gal sensitization and clinical reactivity.  One study demonstrated a correlation between alpha-gal-specific IgE antibody levels and exposure to an intestinal parasite called Ascaris lumbricoides (i.e., round worm).  Moreover, some data suggest that bee and wasp stings may also contribute to the production of alpha-gal-specific IgE, particularly in beekeeping populations. Besides muscle and organ meats, dairy products have also been implicated in triggering reactions.  Additionally, gelatin, (commonly derived from the connective tissue, bones, and hides of mammals), often retains the alpha-gal epitope and is frequently used in products such as gummy candies, marshmallows, and gelatin desserts. Individuals with blood group B appear partially protected against sensitization. This protection is likely due to structural similarities between the blood group B antigen and alpha-gal, resulting in the reduced immunologic recognition in B or AB individuals. Cofactors such as exercise, alcohol, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (i.e., Advil, Motrin) and naproxen (i.e., Aleve, Naprosyn) are frequently reported to enhance the likelihood, timing, and/or severity of the reactions. These cofactors may amplify allergic responses by increasing the gastrointestinal absorption of alpha-gal and/or lowering the reaction threshold. Alpha-gal syndrome differs from the common IgE antibody-mediated food (e.g., nuts, peanuts, fish, shellfish) allergy in 2 important aspects. In a typical food allergy scenario, the individual is sensitized to a particular protein, whereas in alpha-gal syndrome, the individual reacts to a carbohydrate in meats and/or mammalian products. Usually, common food-triggered allergic reactions may cause symptoms within an hour after ingestion, however, clinical manifestations from alpha-gal syndrome are typically delayed, characteristically beginning 2 to 8 hours after exposure to the mammalian product. The classical manifestations of alpha-gal syndrome may include generalized itching (i.e., pruritus), hives (i.e., urticaria), and/or soft tissue swelling (i.e., angioedema) of the lips, tongue, eyelids, etc.  In more severe cases, difficulty in swallowing, shortness of breath, wheezing, and/or life-threatening anaphylaxis may ensue.  Gastrointestinal symptoms such as abdominal pain, cramping, nausea, vomiting, and/or diarrhea are also common.  The gastrointestinal symptoms are more common in children and may be the sole presenting symptom(s). The diagnosis rests on a comprehensive history, focusing on symptom timing, dietary exposures, and any history of tick bites.  The most commonly used diagnostic test is the measurement of the specific IgE antibody to alpha-gal in a blood sample.  A level above 0.1 IU/mL is considered positive and diagnostic.  The IgE antibody to alpha-gal testing is the preferred method since skin food prick testing to mammalian meats can be negative in those found to have a positive IgE against alpha-gal.  It should be noted that most people with a detectable IgE to alpha-gal will also have detectable IgE to extracts from mammalian meats such as beef, pork, lamb, venison, etc. If the clinical suspicion for mammalian meat allergy remains high but the initial serum IgE to alpha-gal is negative, then skin prick and serum IgE testing to beef, pork, and lamb may be considered, as this may be helpful with diagnosing other non-alpha-gal forms of meat allergy.  As an aside, if the patient primarily reacts to pork, checking for sensitivity to cat via skin prick or serum IgE testing may be warranted to rule out pork-cat syndrome, which is due to cross-reactivity between cat and pork serum albumin. In order to prevent the development of acute reactions, the core management principle of alpha-gal syndrome is to avoid mammalian meat and associated visceral organs. The mammalian meats usually implicated are beef, pork, lamb and venison, though all non-primate mammalian meat can be causative. Ingestion of meat or products from bison, buffalo, whale, rabbit, horse, goat, and other mammals should also be avoided.  Additionally, it is important to highlight to patients that mammalian fats used in cooking (i.e., lard, tallow, casings derived from pork which can be used in poultry-based sausages) are also to be avoided. Many patients with alpha-gal syndrome will be able to tolerate dairy products. However, if the reactions continue while avoiding meats, dairy products and gelatin-containing foods/medications should also be avoided. The treatment of reactions depends on the clinical manifestations.  Antihistamines may be helpful in treating itching and rashes, but more severe systemic reactions such as anaphylaxis need to be treated with an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick) or an epinephrine-containing nasal spray such as Neffy.  Some reactions may also require intravenous hydration, albuterol inhalation, and/or oxygen supplementation.  It should be noted that if an individual uses their epinephrine auto-injector device or their epinephrine-containing nasal spray, they should go immediately to the closest emergency room. As tick bites have been associated with the development of alpha-gal syndrome, a reasonable prevention tactic is obviously to circumvent sensitization through the avoidance of tick bites.  There is data showing that the higher the number of tick bites, the higher the alpha-gal IgE levels, highlighting the importance of avoiding subsequent tick bites after sensitization.  Avoiding wooded areas, treating gear with the insecticide permethrin, and using insect repellants will reduce the likelihood of a tick bite. Full body checks should be performed after outdoor activities, and if ticks are found, they should be removed with a fine tipped tweezer. Some patients with alpha-gal syndrome will be able to tolerate meat again with continued avoidance of recurrent tick bites.  In order to determine when and if that person can again tolerate meat, serial monitoring of alpha-gal IgE levels and oral meat challenges may be performed in order to assess the readiness of that individual to consume meat. The board certified allergists at Black & Kletz Allergy have been diagnosing alpha-gal syndrome for many years.  At Black & Kletz Allergy, we treat both adult and pediatric patients. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All 3 of our offices have on-site parking.  For further convenience, our Washington, DC and McLean, VA offices are Metro accessible.  Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line.  For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  If you think that you have an allergy or sensitivity to meat, we are here to help diagnose your problem and help differentiate whether your symptoms are a meat allergy, meat sensitivity, or alpha-gal syndrome.  Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, compassionate, and professional environment.

Allergic to Penicillin Update

December 16, 2025 | Black & Kletz Allergy

Adverse reactions to medications are very common.  Among the drugs associated with immediate hypersensitivity reactions (i.e., IgE antibody-mediated allergic reactions), penicillins are the most commonly observed. Penicillin allergy is reported in approximately 7 to 10% of the community population and it occurs in up to 20% of hospitalized patients.  However, more than 90% of these patients do not have true penicillin allergy, which can be ruled out with the help of a standardized testing procedure.  These patients are mislabeled as having a penicillin allergy which can be deleterious to them as penicillins will be avoided in the future for often less effective and more costly alternative antibiotics. There are 3 common causes for this high rate of false positive penicillin allergy reports:

1. Mislabeling of a side effect (i.e., gastrointestinal upset) as an “allergy”
2. Coincidental event (i.e., headache or rash due to an underlying infection)
3. Loss of true sensitivity over time with avoidance of penicillins

Penicillin skin testing was introduced as a diagnostic intervention for the evaluation and management of patients with a history of penicillin allergy in the 1960’s.  This procedure is commonly performed and has minimal risk.  Penicillin skin testing can be performed safely in properly selected patients with suspected penicillin allergy such as in pregnant women with streptococcal infections. The procedure for penicillin skin testing involves 3 stages:

1. Skin prick testing with a small amount of diluted penicillin antigens, that are commercially prepared testing reagents, with negative and positive controls.
2. If the prick tests are negative after 20 minutes, a tiny quantity of the antigen is injected into the superficial layers of the skin (i.e., intradermal skin test).
3. If the intradermal skin test in the second stage above is also negative after 20 more 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 adverse effects, the patient can receive penicillins if needed, without an increased risk of an immediate allergic reaction.  The negative predictive value of penicillin allergy testing is more than 99%. Penicillin allergy testing should be performed in a health care setting only by clinicians with the knowledge, training, and experience to select appropriate patients for this procedure, interpret test results, and manage a systemic allergic reaction should it occur. Unverified penicillin allergy in hospitalized patients is associated with longer hospital stays and increased rates of serious drug-resistant infections.  The alternative antibiotics to penicillin can be associated with higher cost and/or a greater risk for untoward effects. For this reason, the “Choosing Wisely” program of the American Board of Internal Medicine Foundation recommended in 2014 that physicians not overuse non-penicillin antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation.  The National Quality Partners’ Antibiotic Stewardship Action Team recommends penicillin allergy skin testing as a component of a comprehensive antibiotic stewardship program. Penicillin allergy testing is associated with an unrealized potential.  This procedure can accurately identify the approximately 9 out of 10 patients who, despite reporting a history of penicillin allergy, can receive penicillins safely. Based on current evidence, the American Academy of Allergy, Asthma and Immunology (AAAAI) believes that performing penicillin allergy testing more frequently so that it becomes more routine will result in reduced costs, enhanced patient safety, and improved outcomes. The board certified allergy doctors at Black & Kletz Allergy are always available for our patients to ask any questions that they may have regarding penicillin allergy testing.  We have been diagnosing adult and pediatric patients with penicillin allergy or possible penicillin allergy for many years in addition to diagnosing and treating patients with other allergic conditions such as other medication allergies,  allergic rhinitis (i.e., hay fever), asthma, eczema (i.e., atopic dermatitis), hives (i.e., urticaria), insect sting allergies, eosinophilic disorders, food allergies, mast cell disorders, and immune disorders for more than 50 years.  We have 3 office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All our offices offer on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  If you would like to be evaluated for a penicillin allergy or any other allergic or immunologic condition, please call us today.  You may also click Request an Appointment instead and we will respond to your request within 24 hours by the next business day.  The allergy specialists at Black & Kletz Allergy pride themselves for providing the highest quality allergy care in the Washington, DC metro area.

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Type 2 Inflammation

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Food Allergies and Thanksgiving

November 12, 2025 | Black & Kletz Allergy

Well, it is that time of year again. A time for getting together with family and friends for the annual ritual of gluttony - I mean Thanksgiving. Although the holiday is generally a festive occasion, some food-allergic individuals find Thanksgiving to be a time of the year where they are more concerned than usual. Individuals with food allergies are always concerned when eating at a restaurant or at someone’s house due to the fear of consuming food that causes them to have food allergy symptoms. On Thanksgiving, however, this fear is intensified because typically the food offered on Thanksgiving at someone’s home is usually made by many different people. Normally, when it is not Thanksgiving, the allergic individual can tell the host/hostess what food allergies they have, and the host/hostess will avoid serving that food or foods. On Thanksgiving however, since there are usually multiple people either preparing or cooking the meal, there is more of a chance that an allergic ingredient will be used simply because the person making the food either was not told about the food allergy, they forgot to avoid using it, or it was not communicated to them about the food allergy by the host/hostess. As a result, more mistakes may be made, and a person is more likely to eat food that he or she is allergic to than in other more intimate gatherings. Common food allergens such as milk, egg, wheat, soy, peanuts, and tree nuts are often found around the Thanksgiving table. Gravy, used for turkey and mashed potatoes, frequently contains the food allergens dairy, soy, and/or wheat. Tree nuts (e.g., almonds) are frequently found on string beans and in some types of stuffing (e.g., chestnuts). Tree nuts and peanuts are common in many desserts such as brownies and pecan pie. Milk (i.e., dairy) and eggs are also used in many baked goods. Although pumpkin allergies are not common, pumpkin pie may contain a host of ingredients that may induce a food allergy in some sensitive individuals. It is significant to note that among various cultures, many families incorporate many ethnic foods in their celebrations. These foods may not be traditional, but they may increase the probability of other allergenic foods such as shellfish, fish, etc. to be the cause of an imminent food allergy. If a person has a serious food allergy, it is sensible for that individual to bring their own food, so they can avoid any potential allergic reaction from food. Although having an allergy to turkey does exit, it is not a common food allergy. It is worth noting however that many people feel sleepy after consuming turkey, particularly on Thanksgiving when large amounts are typically eaten. The reason for the sleepiness may stem from the fact that turkey contains higher levels of the amino acid “L-tryptophan.” The amino acid L-tryptophan is an essential amino acid that has to be obtained from foods we eat since the body does not make L-tryptophan on its own. Amino acids are the precursors to proteins and it takes many amino acids to create a protein. Thus, amino acids are considered to be the “building blocks” of proteins. It is also important to mention that there are many other foods besides turkey that are rich in L-tryptophan. Some of these foods include oats, eggs, canned tuna, fish, legumes (e.g., soybeans, peanuts, lima beans), milk, cheese, yogurt, seeds (e.g., pumpkin, sunflower, sesame), bread, chocolate, and some fruits. It should be stated that turkey and chicken both have comparable amounts of L-tryptophan. Another thought-provoking fact is that the dark turkey meat has less of the amino acid L-tryptophan than the white turkey meat, but with chicken, it is the opposite, as there is less L-tryptophan in white chicken meat than dark chicken meat. After eating turkey, the L-tryptophan will enter one’s bloodstream from the digestive tract and travel to the brain where it gets converted to the chemical “serotonin.” It is the serotonin that is responsible for causing the sleepiness associated with eating turkey. It should also be pointed out that eating a high carbohydrate, high fat meal can also lead to sleepiness and fatigue about 1-2 hours after eating. Serotonin, however, is a chemical in the brain that plays a role in one’s mood, as well as pain intolerance. High serotonin levels are associated with elevated moods and a sense of relaxation. Serotonin may also increase one’s pain tolerance. In addition, L-tryptophan is thought to have a beneficial effect on learning, memory, and depression. Serotonin may also have useful effects on decreasing anxiety, premenstrual pain, and seasonal affective disorder although more research is needed to verify this. So, if you experience sleepiness at the Thanksgiving Day table, it may not be your in-laws at all, it may be the turkey! Likewise, if you are in a good mood and feel less depressed during Thanksgiving, it may be that you are happy to be with family, but it still could be the turkey! The board certified allergists at Black & Kletz Allergy diagnose and treat both adult and pediatric patients. We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. 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. You may also click Request an Appointment and we will respond within 24 hours by the next business day. Black & Kletz Allergy has been a fixture in the greater Washington, DC, Northern Virginia, and Maryland metropolitan community for over 50 years for our outstanding services for the diagnosis and treatment of allergic, asthmatic, and immunological conditions.

Rhapsido – A New Treatment for Chronic Urticaria (Hives)

October 23, 2025 | Black & Kletz Allergy

Urticaria (i.e., hives) are itchy red blotches or “welts” that generally occur on the skin but may also occur internally on various parts of the body.  The lesions can be flush with the skin, but are usually slightly elevated above the skin surface, similar to a mosquito bite.  Approximately 20 to 30% of the population will develop hives at some point during their lifetime. Individual skin lesions typically subside in less than 24 hours, although an individual may have multiple crops of lesions in a single day.  In some individuals however, complex hives caused by the inflammation of blood vessels in the skin may last more than 24 hours and leave residual marks on the skin after their resolution. In a majority of instances, the episodes of hives subside spontaneously within a few weeks, however, if the condition lasts longer than 6 weeks, it is termed chronic urticaria.  Alternatively, if the hives last shorter than 6 weeks in duration, the condition is referred to as acute urticaria.  Sometimes hives are associated with the swelling of soft tissues (i.e., angioedema) commonly involving the eyelids, lips, throat, and/or tongue.  It should be noted that angioedema can occur anywhere on or in the body as they can also appear internally. The itching (i.e., pruritus) severity can run the spectrum from very mild to very severe and may be present both during day and/or night.  It can impact one’s quality of sleep at night, impair one’s concentration in school or work during the daytime, thus adversely impacting one’s overall quality of life. Common triggers for hives may include a side effect of a medication, allergic sensitivity to foods, and/or viral infections.  In the vast majority of cases however, there will be no identifiable triggering factor(s) and as a result, it is referred to as chronic spontaneous urticaria (CSU).  If exposure to cold, heat, water, vibration, or pressure triggers hives, it is characterized as chronic inducible urticaria (CIU). A thorough and comprehensive history of the onset, duration, severity, and exposure to possible triggers may provide clues to the causation of the condition.  A few screening laboratory tests are usually obtained in order to rule out systemic disorders which could manifest as chronic spontaneous urticaria.  In most instances (approximately 95%) however, the screening tests will be normal an no identifiable cause will be found. Although no cause can be identified in most cases, the treatment of hives is usually quite manageable.  Medications can be very helpful in relieving the bothersome itching that is often associated with hives.  Medications are also used to lessen the frequency and severity of the actual hives themselves.  Histamine, a chemical released into the blood stream from both mast cells and basophils (i.e., types of white blood cells) is the principle chemical mediator that causes the clinical manifestations of both acute and chronic urticaria. Medications which block the actions of histamine on the skin are usually first line treatment options.  Second-generation antihistamines such as Claritin (i.e., loratadine), Allegra (i.e., fexofenadine), Zyrtec (i.e., cetirizine), and Xyzal (i.e., levocetirizine) are less sedating than the first-generation antihistamines such as Benadryl (i.e., diphenhydramine) and Atarax (i.e., hydroxyzine).  It should be noted that many patients do not respond adequately to the regular doses of antihistamines used in the treatment of environmental allergies.  Depending on the response, the doses of these agents may be gradually increased up to 4 times the regular daily dose, if recommended by the allergist and monitored closely.  If the symptoms continue to be bothersome, first-generation antihistamines such as Palgic (i.e., carbinoxamine) or Periactin (i.e., cyproheptadine) can be added to the regimen. As we understand more and more about the underlying immunological mechanisms and the molecular mediators of these conditions, newer medications targeting these pathways and/or blocking these molecules are being developed. When antihistamines alone are ineffective, biological medications such as Xolair (i.e., omalizumab) and Dupixent (i.e.,  dupilumab) can offer significant relief from symptoms.  Xolair was the first biologic approved for chronic spontaneous urticaria and many patients have greatly benefited from this medication over the past several years.  It is usually given as an injection under the skin (i.e., subcutaneously or SQ) every 4 weeks. Dupixent was the second biologic medication approved for chronic spontaneous urticaria in April 2025 and is administered as a subcutaneous injection (SQ) every 2 weeks. The most recently approved medication for chronic spontaneous urticaria called Rhapsido (i.e., remibrutinib) inhibits an inflammatory mediator called Bruton’s tyrosine kinase (BTK).  BTK is an intracellular protein expressed in mast cells, basophils, as well as other cells and is involved in intracellular signaling.  Clinical trials have shown a 70% reduction in hives vs. a 39% decrease in hives with the placebo at week 12.  It has also been shown to reduce itching by 67% vs. a decrease of 42% with the placebo. Rhapsido got approval from the FDA in September 2025 for the treatment of chronic hives in adults with no known external triggers and who are not controlled with antihistamines.  The dosage is a 25 mg pill taken by mouth twice daily.  Rhapsido may be taken with or without food.  It would be a good option for patients who are needle phobic or in patients who do not respond adequately to Xolair or Dupixent. The board certified allergy specialists at Black & Kletz Allergy will promptly answer any questions you may have regarding both acute or chronic urticaria (i.e., hives) or any related condition such as generalized itching (i.e., pruritus) or swelling episodes (i.e., angioedema).  Our allergy doctors have been diagnosing and treating hives in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  We have 3 convenient locations in the Washington, DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  There is on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call us at any one of our 3 locations.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy is dedicated in providing the most current diagnostic and treatment methods in the field of allergy, asthma, and immunology in a caring and professional setting.

The Association Between Asthma and GERD (Acid Reflux)

October 10, 2025 | Black & Kletz Allergy

Individuals with asthma probably are unaware of the association between asthma and acid reflux (GERD). It is estimated that approximately 75% of asthmatics have GERD of some degree. GERD or acid reflux occurs when there is a backflow of stomach contents into the esophagus (i.e., swallowing tube). In other words, the stomach contents travel in the wrong direction and enter the esophagus, instead of the small intestines. People with GERD often complain of “heartburn,” which in reality is a burning sensation in the chest and/or throat usually in conjunction with a sour or bitter taste in the mouth. In addition, some individuals may experience other symptoms which may include sore throat, burping, abdominal bloating, nausea, wheezing, coughing, and/or the sensation that something is caught in one’s throat. It is the wheezing and coughing symptoms that cam mimic asthma in individuals without asthma. In true asthmatics, acid reflux may actually worsen their asthma symptoms, not just mimic them. In patients with asthma, the typical asthma symptoms of chest tightness, coughing, wheezing, and/or shortness of breath may be aggravated if the underlying acid reflux is not treated appropriately. The first way this may occur is via small amounts of acid irritating the airways (similar to a chemical burn) which may in turn cause asthma symptoms. The second method may involve the triggering of a reflex in the airways to become narrower in order to prevent more acid from entering the airways. It is this narrowing of the airways that causes an individual with asthma to cough, wheeze, cough, experience chest tightness and/or feel short of breath. In addition to the 2 methods above, some asthma medications may decrease the lower esophageal sphincter pressure thus relaxing this muscle which in turn will increase the severity of GERD or acid reflux. Asthma medications in the bronchodilator family such as albuterol (i.e., Proventil, ProAir, Ventolin, AccuNeb), terbutaline (i.e., Brethaire, Brethine), vilanterol, ipatroprium (i.e., Atrovent), salmeterol (i.e., Serevent), formoterol, (i.e., Foradil), levalbuterol (i.e., Xopenex), and Tiotropium (i.e., Spiriva) fall into this category. There are also asthma medications that are combinations of two or more medications, one of which is a bronchodilator, which can therefore increase acid reflux disease. The names of some of these medications include Advair, Dulera, Breo Ellipta, Symbicort, Combivent, AIRSUPRA, Trelegy, and DuoNeb. Theophylline (i.e., Theo-Dur, Uniphyl, Slo-Bid, Theo-24), an older but still useful oral bronchodilator asthma medication, has also been associated with an increase in GERD in patients by causing the relaxation of the lower esophageal sphincter as well. Interestingly, the chemical structure of theophylline is similar to that of caffeine which is another trigger of GERD. It is a double edge sword because not only can acid reflux exacerbate one’s asthma, but asthma can also make one’s acid reflux worse. In addition to asthma making one’s acid reflux worse, there are several risk factors that may contribute to GERD and some of them may include obesity, alcohol use, diabetes mellitus, pregnancy, smoking, connective tissue diseases (e.g., systemic sclerosis or scleroderma), eating large meals, eating before bed, hiatal hernia, certain medications [e.g., aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), oral corticosteroids, bronchodilators, calcium channel blockers], and/or certain foods [e.g., caffeine, spicy foods, .garlic, onions, fatty foods, acidic foods (soda, citrus fruits, tomatoes)]. The diagnosis of GERD can be made by performing a comprehensive history from the patient along with observing relief when taking anti-reflux medications such as antacids and/or acid-blocking medications. If there is no improvement in acid reflux symptoms, there are several procedures that can be performed in order to help establish the diagnosis of acid reflux disease. Some of these procedures include upper endoscopy with or without a biopsy, barium swallow, pH monitoring (checks the acidity in the stomach), and esophageal manometry (checks the function of the lower esophageal sphincter and esophagus). The treatment of GERD is directed at reducing the risk factors mentioned above as well as prescribing acid-blocking medications and antacids. By treating the underlying GERD in patients who are asthmatic with associated GERD, the symptoms of asthma (i.e., chest tightness, coughing, wheezing, and shortness of breath) may also be reduced. The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating asthma for more than 50 years. We treat both pediatric and adult and 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, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from asthma or allergies, we are here to help relieve or hopefully end these undesirable symptoms that have been so bothersome, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a calm, compassionate, and professional environment.

Allergy Nasal Spray Prevents COVID?

September 26, 2025 | Black & Kletz Allergy

SARS-CoV-2 is the name of the coronavirus that is responsible for the COVID-19 pandemic that caused millions of deaths worldwide.  Although vaccination and established population immunity have substantially mitigated the severity of acute SARS-CoV-2 infections, the virus continues to infect millions of people resulting in a number of hospitalizations and deaths.  There is a need for an effective pre-exposure prophylaxis for the general population, particularly for high-risk groups such as individuals with preexisting conditions and the elderly. Azelastine is a second-generation antihistamine, which is commonly used as a nasal spray under the trade name Astelin or Astepro.  It is used for and quite effective for the relief of perennial and seasonal allergic rhinitis (i.e., hay fever) symptoms such as sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, sinus congestion, sinus headaches, itchy eyes, puffy eyes, watery eyes, and/or redness of the eyes.  Azelastine also has previously demonstrated anti-viral activity against respiratory viruses such as influenza (i.e., flu), respiratory syncytial virus (RSV), and some coronaviruses, in addition to its anti-allergic and anti-inflammatory properties. Clinical trials have demonstrated that azelastine nasal spray reduces viral load in patients with confirmed SARS-CoV-2 infection, suggesting therapeutic efficacy in the acute treatment of COVID-19.  These findings prompted researchers to study whether azelastine can also be used as a prophylaxis to prevent Covid-19 infection. In a clinical trial published in the Journal of American Medical Association-Internal Medicine this month (September 2025), a team of investigators attempted to shed further light on this topic.  They recruited 450 healthy volunteers who were 18 to 65 years of age with no signs of an acute infection for the study.  Participants were randomly assigned 1:1 to receive azelastine 0.1% nasal spray or placebo 3 times a day for 56 days.  SARS-CoV-2 rapid antigen testing (RAT) was conducted twice a week with positive results confirmed by polymerase chain reaction (PCR). The primary end point was the number of polymerase chain reaction-confirmed SARS-CoV-2 infections during the study.  The results of the trial revealed that the incidence of PCR-confirmed SARS-CoV-2 infection was significantly lower in the azelastine group compared with the placebo group.  As secondary end points, azelastine demonstrated an increase in mean time to SARS-CoV-2 infection among infected individuals, a reduction of the overall number of PCR-confirmed symptomatic infections, and a lower incidence of PCR-confirmed rhinovirus infections.  Note that rhinovirus is the most common cause of the common cold. Adverse events were comparable between the groups, except for a bitter taste which was experienced by more individuals in the azelastine group compared to placebo.  Azelastine nasal spray has long been known to cause a bitter taste in one’s mouth in patients using the nasal spray for the treatment of allergic rhinitis. The nasal mucus membrane, as the primary site of viral entry and replication, plays a critical role in the pathogenesis of respiratory viral infections.  The ability of locally applied and locally acting azelastine nasal spray to significantly reduce SARS-CoV-2 and overall upper respiratory tract infections underscores the efficacy of topical nasal interventions. The findings of this randomized clinical trial suggest that azelastine nasal spray may reduce the incidence of respiratory infections caused by SARS-CoV-2.  Although not studied yet, maybe other nasal antihistamines such as olopatadine (i.e., Patanase) may also reduce or prevent the incidence of respiratory infections caused by SARS-CoV-2. The board certified allergy specialists at Black & Kletz Allergy have 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 the McLean, VA office and the Spring Hill metro station on the silver line.  The allergy doctors at Black & Kletz Allergy are extremely knowledgeable regarding allergic rhinitis (i.e., hay fever) as well as non-allergic rhinitis.  We are very experienced using azelastine for the treatment of allergic rhinitis.  We diagnose and treat both adult and pediatric patients.  In addition, we treat patients with food, insect sting, medication, and skin allergies, as well as asthma, sinus disease, eosinophilic esophagitis, and immunological disorders.  To schedule an appointment, please call any of our offices or you may alternatively click Request an Appointment and we will respond within 24 hours by the next business day.  We have been servicing the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 5 decades and we look forward to providing you with comprehensive state-of the-art allergy care in a welcoming and professional environment.

Autumn Allergies

September 26, 2025 | Black & Kletz Allergy

Autumn has just begun and for some people it is a bittersweet moment.  Although many individuals enjoy the lower temperatures that the autumn brings in the Washington, DC, Northern Virginia, and Maryland metropolitan region, many allergy sufferers are not so welcoming because with the lower temperatures, mold and weed pollen levels rise.  The major weed culprit in the DC area is ragweed, although many other weed pollens increase during the Fall such as pigweed, sorrel, dock, milkweed, and lamb’s quarters.  In the U.S., ragweed allergy is common as approximately 10% of the population suffers from ragweed pollen.  Approximately 50% of all pollen-associated allergic rhinitis (i.e., hay fever) in North America is due to ragweed, particularly in the Eastern and Midwestern regions.  Ragweed also causes allergic conjunctivitis (i.e., eye allergies) and asthma in other sensitive individuals. There are 17 species of ragweed in North America.  The only state in the U.S. without ragweed is Alaska.  Each ragweed plant produces approximately 1 billion pollen grains. The ragweed plant lives only 1 season.  Although ragweed is almost ubiquitous in the U.S., the pollen is even more widespread in rural areas.  Ragweed is typically found along the side of the road, in vacant lots, in fields, and along riverbanks.  Environmental factors play a role in the release of ragweed pollen.  The warm weather in combination with the wind and increased humidity augments the release of ragweed pollen which in the mid-Atlantic region tends to begin in mid-August, peak in mid-September, and end with the first frost which typically occurs in late October.  The ragweed pollen count tends to be its highest during the midday and lowest in the early mornings.  The pollen released from the ragweed plant can travel hundreds of miles, like other pollens, so most of the U.S. population is exposed. Most weed-sensitive individuals complain of the typical allergy symptoms associated with allergic rhinitis or allergic conjunctivitis.  The symptoms may include sneezing, runny nose, nasal congestion, post-nasal drip, sinus congestion and pressure, sinus headaches, fatigue, itchy nose, itchy throat, snoring, itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes.  Individuals with asthma may also have an exacerbation of their asthma with symptoms such as wheezing, coughing, chest tightness, and/or shortness of breath.  Patients prone to sinus infections (i.e., sinusitis) may develop a sinus infection during the autumn as a result of the high weed pollen count. In addition to weeds, there are other environmental allergens that may be responsible for an uptick in allergy symptoms to allergic individuals in the autumn.  Besides ragweed and other weeds, molds, dust mites, pets, and cockroaches are common allergens that may play a role in inducing allergic rhinitis, allergic conjunctivitis, and/or asthma symptoms in susceptible individuals.  In fact, all of these allergens are perennial and may be bothersome to sensitive individuals throughout the year, not only in the autumn.  In particular, leaf mold is quite annoying to many allergy sufferers, particularly to people who like to garden and rake leaves.  It should be noted that dust mites, pets, and cockroaches are indoor allergens whereas weeds are outdoor allergens.  Molds, however, are both indoor and outdoor allergens and are particularly bad in the Washington, DC metro area because DC was built on a swamp and there is high humidity in this region. It is also interesting to note that there are certain foods that are closely associated with ragweed such that when eaten by ragweed-sensitive individuals, they may experience an itchy mouth, throat, and/or lips.  People with this condition are said to have oral allergy syndrome or pollen-food allergy syndrome.  It occurs in response to eating certain raw or uncooked fruits, vegetables, and/or nuts by the ragweed-sensitive person.  Occasionally, one may experience itching of the hands when touching raw foods.  Some examples of foods associated with ragweed pollen allergy include banana, melon (e.g., honeydew, cantaloupe, watermelon), chamomile tea, cucumber, zucchini, white potato, dandelion, sunflower seeds, and artichoke.  Although ragweed-sensitive patients may develop an itchy mouth, throat, and/or lips when they eat these foods raw or fresh, when the fruit or vegetable is cooked or canned, the protein is denatured and thus destroyed which usually prevents the allergic reaction from occurring.  In most cases, individuals are able to tolerate cooked and/or canned fruits and vegetables.  Of note, oral allergy syndrome may also occur in individuals who have other pollen allergies such as tree pollen.  A classic example of this is that some individuals who have birch tree allergies will have itching of the mouth, throat, and/or lips when eating raw or fresh pitted fruits (e.g., apples, peaches, plums, pears).  Extra caution needs to be taken in cases where nuts cause symptoms because many individuals can have a classic nut allergy that is not associated with pollen which may be life-threatening.  Such individuals should be prescribed a self-administered epinephrine device such as an EpiPen, Auvi-Q, Adrenaclick, or Neffy, an epinephrine containing nasal spray.  Patients should be instructed that if they use the self-administered epinephrine device, they should go immediately to the closest emergency room. The board certified allergists at Black & Kletz Allergy has 3 convenient locations in the Washington, DC metro 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 by the next business day.  The allergy specialists of Black & Kletz Allergy are eager to help you with your autumn allergies (i.e., hay fever), asthma, hives, swelling episodes, mast cell condition, eosinophilic esophagitis, sinus issues, or any other allergy and immunology problems.  We are dedicated to providing first-rate care to you as we have been doing in the Washington, DC metro area for more than 50 years.

Alpha-Gal Syndrome Update

August 18, 2025 | Black & Kletz Allergy

Over the last 10-15 years, the number of individuals with meat allergy has risen mainly because of a condition called alpha-gal syndrome or mammalian meat allergy.  Alpha-gal syndrome was first identified by Dr. Thomas Platts-Mills at the University of Virginia School of Medicine in 2002.  He discovered that the syndrome originated from the bite of lone star ticks (Amblyomma americanum).  Specifically, the IgE antibody (i.e., the allergy antibody) response to the mammalian sugar molecule known as alpha-gal was associated with a delayed-onset swelling (i.e., angioedema) and/or anaphylaxis 2 to 8 hours after eating mammalian food products, such as beef, lamb, pork, and/or venison. Alpha-gal, officially referred to as galactose-alpha-1,3-galactose, is a carbohydrate (i.e., sugar molecule) that exists in most mammals (e.g., pigs, cows, deer, sheep, rabbits, whales).  It is not found however in humans or non-mammals such as birds, reptiles or fish.  Lone star ticks can transfer this alpha-gal carbohydrate molecule to humans by first biting and feeding on mammals and then biting humans.  After someone is bitten by a lone star tick, the alpha-gal molecule, which is present in the tick’s saliva, is transmitted into the individual’s bloodstream.  In turn, that person will produce IgE antibodies as a defense mechanism against this foreign carbohydrate molecule (i.e., sugar molecule).  As a result, that person now has alpha-gal IgE antibodies present in their bloodstream.  Going forward, after the sensitization to alpha-gal occurs, whenever that individual eats mammalian meat which naturally contains the sugar molecule galactose alpha-1,3-galactose (i.e., alpha-gal), their alpha-gal IgE antibodies will bind and react against the alpha-gal present in the mammalian meat (e.g., pork, beef, venison, lamb, rabbit, whale) and cause the person to exhibit allergic symptoms.  The typical and more common symptoms experienced by someone with alpha-gal syndrome include hives (i.e., urticaria), swelling (i.e., angioedema) and/or anaphylaxis in more severe cases. There is also a newer variant of alpha-gal syndrome referred to as gastrointestinal (GI) alpha-gal.  Gastrointestinal alpha-gal presents with GI symptoms such as nausea, vomiting, diarrhea and/or abdominal pain without the predominant skin, respiratory, or circulatory symptoms.  It should be noted that there are IgE antibodies present on human mast cells that richly populate the gastrointestinal tract.  In patients with the variant called gastrointestinal (GI) alpha-gal, as a result of the binding of the alpha-gal molecule with the IgE antibodies on the mast cells in the gastrointestinal tract, degranulation of the mast cells occur which causes the release of large amounts of histamine and other inflammatory chemical mediators into the bloodstream.  These chemical mediators can in turn act on sensory nerve endings to cause the intestinal smooth muscles to cause contractions which produce pain as well as the mucous glands in the GI tract to produce more mucous.  Note that these vague abdominal symptoms can be and often are confused with other gastrointestinal conditions such as irritable bowel syndrome (IBS) or classic food allergies.  One way to differentiate between a common food allergy and alpha-gal syndrome is that onset of symptoms is typically several hours after the ingestion of the mammalian meat in patients who have alpha-gal syndrome.  A history of waking up at night from sleep with gastrointestinal distress may suggest that the person has alpha-gal syndrome given the delay in symptoms that occurs in this condition.  In individuals with classic food allergies, the abdominal symptoms usually occur fairly quickly after ingesting the offending food. Diagnosis: The diagnosis of alpha-gal syndrome begins by performing a comprehensive history and physical examination.  The diagnosis is helped if there has been a recent tick bite, although it is not crucial to make the diagnosis as not all patients remember if they have had a recent tick bite.  A blood test for alpha-gal antibody should be taken and laboratory findings are positive for the alpha-gal antibody in individuals with the condition.  The diagnosis is often not made due to the fact that there is usually a time period between the tick bite and the advent of symptoms.  Thus, the diagnosis is typically underdiagnosed.  Note that the gold standard to diagnose regular IgE-mediated food allergies is the oral food challenge, but in the case of alpha-gal syndrome, the oral food challenge is unreliable since there is typically a delay in symptoms for several hours after the ingestion of mammalian meat. Treatment: Eliminating the consumption of all mammalian meat (e.g., beef, pork, venison, lamb, rabbit, whale) and mammalian products (e.g., milk, butter, lard) is the only way to manage this condition.  Dairy products do contain smaller amounts of alpha-gal, particularly cream cheese, cream, and ice cream, cream, which have a high fat content.  Gelatin is derived from the collagen in pig or cow bones.  As a result, foods that contain gelatin (e.g., gelatin candies, gummy bears, marshmallows) may likewise trigger allergic reactions.  Processed foods can also have small amounts of animal-derived products.  Restaurants may cross-contaminate foods with alpha-gal which may be a problem for individuals with high levels of sensitivity to alpha-gal. Prevention: The treatment of alpha-gal syndrome is simply prevention.  Patients with alpha-gal syndrome should take actions to avoid further tick bites because additional lone star tick bites may worsen the allergy.  Checking regularly for ticks, showering soon after outdoor activities in grassy and woody areas, treating clothes and shoes with permethrin, and creating a barrier at the ankles by pulling up one’s socks over the pant cuffs when outside may all help reduce the likelihood of tick bites. Certain medications such as cetuximab (i.e., Erbitux) and pancreatic enzymes are derived from pigs and may cause problems in individuals with alpha-gal syndrome.  A company in Blacksburg, VA has developed alpha-gal-free pork, which is FDA-approved but not yet widely available.  Another option for alpha-gal allergic individuals is to consume plant-based substitutes to meat commonly found in companies such as Beyond Meat or Impossible Burger. All patients diagnosed with alpha-gal allergy should carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) or an epinephrine nasal spray (e.g., Neffy) for use in case of a systemic reaction following an unintended exposure to mammalian meat.  If a self-injectable epinephrine device or an epinephrine nasal spray is used, the patient should go immediately to the closest emergency room. The board certified allergy doctors at Black & Kletz Allergy have been diagnosing and treating allergies, asthma, sinus conditions, and immunological disorders for more than 5 decades.  Black & Kletz Allergy has 3 convenient locations in the Washington, DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We offer on-site parking at each location and the Washington, DC and McLean offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  Please call us today to make an appointment at the office of your choice.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergists at Black & Kletz Allergy pride themselves in delivering the highest quality allergy care in the Washington, DC metropolitan area in conjunction with providing excellent customer service in a welcoming and pleasant environment.