Wheezing and Sneezing are Not Always Signs of Allergy

The obvious underlying cause of sneezing may not necessarily be the right one.

The obvious underlying cause of sneezing may not necessarily be the right one.

In medicine it’s all too easy to assume that a certain symptom is representative of a specific diagnosis. Since allergic symptoms are so common, this is a pitfall we need to be wary of. There’s an old adage, “All that wheezes isn’t asthma.” I’ll add to that “all that sneezes isn’t allergic rhinitis.” Often the only way to establish a definitive diagnosis is through diagnostic testing.

A patient’s history is, of course, the foundation of a correct diagnosis for any medical condition. However diagnostic testing, when available, is invaluable in either supporting a presumptive diagnosis or showing us where we’ve been misled. It’s generally believed that 80% of asthma is extrinsic (allergic) in nature, so one cannot fault a clinician for assuming asthma is due to inflammatory bronchoconstriction, and that an inhaled steroid plus a beta-agonist inhaler should be an effective treatment. But that assumption may be incorrect and the treatment regimen ineffective. I would strongly suggest obtaining a pulmonary function test (PFT) in these patients. A PFT can differentiate between an obstruction due to temporary airway constriction, which may be quickly reversible, and a restriction, which indicates that the fundamental problem is not asthma but another airway disease.

Chapter 8 of my book, Dr. Dean Mitchell’s Allergy and Asthma Solution (Marlowe 2006), addresses “Diseases that Masquerade as Asthma and Allergies.” The following case is typical of those in the book… The patient was a 60-year-old black African American female. She had been experiencing “a whistle in her chest” for about two months. She had coughing episodes and sometimes wiped a couple of drops of blood from her mouth. Her son, a patient of mine, insisted his mom come to see me to be tested for allergies. I knew her son had a lot of allergies however I found it strange that she had no history of allergies or asthma until her seventh decade. Late-onset asthma always alerts me to look for an underlying cause. I tested her for allergies which revealed positives for ragweed and dust mites, similar to her son — but I was still uneasy. I ran a PFT, which revealed a low FEV1 of 70%. While this result could be consistent with the diagnosis of asthma, she also had a low FVC, indicating some restriction. So I ordered a chest-X ray which demonstrated some fluid in the left lower lung field. I reviewed these findings with the radiologist and he recommended a CT scan. The findings on the CT scan unfortunately indicated an endobronchial adenocarcinoma which was blocking her airway and causing the wheezing. In my 22-years in practice, this was the only such case, but it was unforgettable.

Another case I’ll never forget involved a patient with chronic rhinitis. This case was not a patient of mine, but the story was delivered by a staffer who shared office space with me. The staffer’s father had chronic nasal congestion and was “addicted” to Afrin. He couldn’t go a day without it, yet he didn’t feel it was necessary to seek care from a physician. In his late 50s he developed heart problems and the doctors determined that he needed coronary bypass surgery. At age 61, he developed acute shortness of breath. An emergency room chest-X ray revealed bilateral pleural fluid. The cause of the fluid was renal failure—his BUN was over 100! Evaluation of his kidney disease led to the diagnosis of Wegener’s Granulomatosis; a condition of vasculitis in which the immune system attacks the blood vessels. Interestingly, Wegener’s patients typically have chronic rhinitis or sinusitis as the initial presentation. If you have a rhinitis patient that has negative allergy skin testing, and the cause is unclear, a simple Erythrocyte Sedimentation Rate (ESR) (or “sed rate”) to identify an underlying inflammatory process can be a valuable clue to a more serious condition.

I like to teach medical students that when “you hear hoof beats, you don’t usually think of zebras.” In real world practice there are a lot more horses. But keep those striped animals in mind because every so often one will gallop your way, and your ability to recognize it can make all the difference in your patient’s life.

– Dr. Dean Mitchell

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Anaphylaxis, The True Allergic Emergency – What You Need to Know

Anaphylaxis, which comes from the Greek term “reverse protection,” is the most

There are many possible signs of anaphylaxis...

There are many possible signs of anaphylaxis…

dangerous type of allergic reaction. It is described as a type 1 Hypersensitivity reaction that involves release of IgE triggered, most often, by a food, medication or insect sting. Anaphylaxis is a frightening reaction where a patient, who moments before appeared fine and healthy, almost within seconds can be wheezing, hypotensive, and covered with hives.

The foods most commonly associated with anaphylaxis in children are peanuts and tree nuts; in their adult counterparts it’s usually shellfish. The confusing part for patients and clinicians is that a food allergy can develop after eating a particular food on many occasions. However, once that threshold has been crossed, even a minute amount of that food can cause an explosive reaction. If a food is the suspected cause of anaphylaxis, but the specific food unclear, it’s wise to evaluate the patient through several steps.

Initially, I would recommend a panel of food allergy blood tests. ImmunoCap is a common one used by most labs to evaluate IgE reactions to specific foods. The results range from zero to six, with a score of at least two indicating a positive reaction. If there is a positive reaction to peanut, the allergy should be further explored by ordering a UKnow Peanut test which analyzes the proteins Ara h1,2&3, as well as Ara h8. My article in Consultant for Pediatricians, “Pinpointing the Proteins in Peanut Allergy,” explains why these proteins are important to predict the severity of peanut allergy. If, for some reason, the blood test is negative, I would recommend referral to an allergist for skin testing and/or oral challenge in case there is a hidden allergen that requires more extensive testing.

Any medication can cause an anaphylactic reaction however the common culprits are antibiotics and non-steroidal anti-inflammatory drugs. Many antibiotics are mold-based, which may be part of the reason for their allergenicity. In the past, beta-lactam antibiotics such as penicillin and related cephalosporins were the most likely offenders but today we also see anaphylaxis to the widely used category of quinolone antibiotics. To complicate matters, it is not unusual for a patient to have multiple antibiotic sensitivities; there is a genetic component to this reaction. While Pre Pen can be used to diagnose penicillin allergy (talk to your AllerVision representative for more information), there is no such test for most antibiotics, and a drug challenge may be required for conclusive diagnosis.

Non-steroidal medications, such as Advil, Motrin and Alleve, work by blocking the cyclo-oxygenase pathway and trigger release of leukotrienes which are potent mediators of anaphylaxis. In my experience, patients allergic to NSAIDS are usually unaware of the source of reaction until they suffer several episodes of anaphylaxis. Be on high alert for NSAID hypersensitivity when evaluating a patient for anaphylaxis or urticaria. Unfortunately, a drug challenge is the only conclusive test NSAID hypersensitivity.

The clinical diagnosis of anaphylaxis can be complicated. The World Allergy Organization recently came out with new criteria. Essentially, it includes exposure to a possible or known allergen and the finding of two or more clinical signs: urticarial, bronchospasm, gastrointestinal distress and cardiovascular collapse. In case of cardiovascular collapse, no additional signs are needed — call 911 and immediately transport the patient to the hospital.

While anaphylaxis is fairly rare with allergy injections, and exceedingly rare with allergy skin testing, it is important that you and your staff be prepared just in case. When a patient is in your office, the question of whether or not to treat a potential reaction is simplified, and doesn’t include an extensive review of the clinical findings nor consideration about number of signs. If you place an allergenic substance on the patient’s skin, or inject them with a substance you know they are allergic to, and they have a reaction anywhere other than the local site of exposure, TREAT THEM! Common signs to look out for are itching of hands and feet, or clearing of throat that wasn’t happening when the patient came in to the office. If you apply antigen to one area of the body, and the patient has symptoms somewhere else, you have to assume that the reaction has gone systemic and you should treat accordingly.

The initial treatment of anaphylaxis is unambiguous: epinephrine intramuscularly into the lateral thigh. Don’t play around with Benedryl! Don’t give a cortisone shot! Anaphylaxis progresses immediately, and neither antihistamine nor steroid drugs act on the spot to reverse the severe pathophysiological reaction. Deaths resulting from anaphylaxis happen when epinephrine is not administered in under 3o minutes from the onset of symptoms. If you are giving allergy injections in your office, you MUST have the patient wait 20 minutes in the office to make sure they don’t have an immediate allergic reaction. If they develop ANY sign or symptom within that time, administer epinephrine. The EpiPen is convenient for an office because it contains the 0.3 ml of epinephrine with the needle size for an intramuscular injection. It also comes as the EpiPen Jr. for children or infants less than 66 lbs. Once epinephrine has been given, the patient must be monitored for several hours to make sure there isn’t a biphasic reaction; this usually takes place in a hospital.

Anaphylaxis can be the most frightening of clinical reactions. The good news is with quick recognition and prompt treatment with epinephrine, you can be a real hero!

– Dr. Dean Mitchell

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