Do You Know What You’re REALLY Allergic To?

Flowering trees do not usually trigger allergies. If you start sneezing when you encounter one, chances are that other trees — or other allergens altogether — are to blame.

Consider this: you walk down the street and see a beautiful tree with blooming purple flowers. As you get closer, you start to sneeze uncontrollably. It’s obvious you’re allergic to the tree, right? Probably not…

First, trees with flowers are usually insect pollinated, not wind pollinated. Pollen carried by insects rarely ever makes it into your system. So if it is pollen that’s causing your reaction, it’s probably not the flowering tree that’s to blame. Then why does it always seem to work that way — you see the flowers, the tree is clearly in bloom, and you start sneezing — if flowering trees are not allergy-inducing? Because they blossom at the same time as wind-pollinated trees. There may be a grove of Juniper trees two miles away and a gust of wind picked up its pollen and delivered it right into your path. Maybe you didn’t even see the Juniper pollen, which makes it an even more likely culprit; the smaller the pollen size, the farther travels and the more easily it sneaks into your nose and lungs. Then again, your allergy trigger could be pollen from recently mown grass or the patch of weeds growing in a nearby field.

Now imagine stepping into the home of a friend. Within minutes, a sinus headache comes on strong. Although there’s no pet present, cat hair covers the couch and a shaft of sunlight reveals dust wafting through the air. Either of those could be a source of your allergy symptoms. In fact, cat protein lives in a home for many months after its furry owner has vacated the scene. Or, cockroaches — completely hidden from view — could be to blame. The roaches may be long gone too, but it’s what they leave behind that gets your histamine flowing.

Last scenario… You take a bite out of an apple and your mouth tingles and your lips feel slightly swollen. Are you allergic to the apple? Hard to believe, since you just had a slice of apple pie and didn’t have any problems. You might be experiencing Oral Allergy Syndrome (OAS). Simply put, the apple is related to certain kinds of pollen to which you are sensitized and, in its raw form, the apple triggers allergy symptoms.

So, how do you tell what you’re really allergic to? There’s only one reliable way — an allergy test. First, when you visit an AllerVision-affiliated provider, your doctor will ask questions to get clues to what allergens MIGHT be to blame. Then you’ll most likely receive a pain-free skin test that will reveal your allergy sensitivities in just 15 minutes. Combined with the questions you answered, your doctor should be able to identify your allergy triggers on the spot so you can discuss treatments. That, of course, is the bottom line — we want you to enjoy the great outdoors — or whatever’s really causing your allergies.

To find an AllerVision-affiliated doctor — who’s qualified to offer allergy examinations — please click here.

Top 7 Reasons Nearly Every Doctor Should Test for Allergies

The allergy skin test is painless, quick and accurate.

Family practitioners, internists, pediatricians, dermatologists, ENTs, neurologists, pulmonologists, ophthalmologists and nearly all other types of physicians and health care providers come in contact with patients who suffer from allergies virtually every day. That’s because allergies cause symptoms in every organ system. In fact, they cause many more symptoms than the average person realizes, including rashes (dermatitis), sinus infections, migraine headaches, dizziness, conjunctivitis, respiratory problems, fatigue, muscle and joint pain, and the list goes on. So here are our top seven reasons your healthcare provider should offer allergy testing — and treatment — in his or her office.

1) Since nearly every type of doctor comes in contact with patients suffering from allergies, it’s important that they are trained and have the tools to properly diagnose those patients’ allergies, suggest appropriate treatment, and know when to refer to an allergy specialist.

2) Allergies affect A LOT of people. The World Allergy Organization estimates that “30-40% of the world’s population is now affected by one or more allergic conditions.” And those numbers are growing; allergies have reached epidemic status.

3) There aren’t enough allergists to go around. Allergists make up a very small percentage of doctors. Even if there were enough, people often don’t know that their illness/ailment/discomfort is caused by allergies. Their primary care doctors should be able to make that diagnosis and offer first line definitive treatment as they do with most other chronic conditions (like hypertension and diabetes).

4) It’s impossible to be sure exactly what’s causing the allergic symptoms without a proper test. Pollens ride on the wind and cause discomfort for people up to hundreds of miles away from their source. Pet hair gets stuck in furniture and carpeting, causing allergic reactions even if the animal has been away for months. Dust mites float through the air and hide in bedsheets. Cockroaches leave hidden “presents” that trigger allergies. Which of these items cause your symptoms? The only way to find out is to test. AllerVision provides doctors with a program that allows them to test for reactions to a wide range of regional allergens and a variety of foods.

5) The allergy skin test is painless, easy to administer in the doctor’s office, and produces results in just 15 minutes. This convenient test, which is the diagnostic gold standard, helps doctors quickly determine the problem and the select the right course of treatment immediately.

6) Allergies can lead to asthma attacks. Asthma is a serious chronic airway disease that causes coughing, wheezing, and difficulty breathing. It often interferes with quality of life, preventing sufferers from participating in sports and outdoor activities. Severe asthma attacks in a patient without adequate disease control can be fatal.

7) Allergies can cause anaphylaxis, an extreme, life-threatening reaction. Anaphylaxis is usually associated with insect stings and food allergies but other allergens can cause it as well. Simply put, knowing what you’re allergic to can save your life.

Healthcare providers who don’t offer allergy testing should consider taking the time to learn and add the service to their practice. For more information, click here.

If you think that you may suffer from allergies, get an allergy test and evaluation. (Hint: if you’re feeling bad and don’t know why, it could be allergies.) AllerVision can help you find a local doctor who performs the test, or we can contact your provider to help him or her launch an allergy testing and treatment program. Click here to learn more.

The Allergy Family History: A Key Component to Diagnosing an Allergic Condition

Family history plays a large role in diagnosing allergies.

Many chronic medical conditions may stem from underlying allergic process: rhinitis, asthma, bronchitis, sinusitis, atopic dermatitis, otitis, conjunctivitis, headache, GI problems and, of course, drug allergies and anaphylaxis. Your physical exam— along with allergy testing — can often help make a specific diagnosis. However the diagnosis begins before you get there. The History is always a key element in the diagnostic process. I have found that, in regards to allergy, the Family History may be the most important component of all.

Allergic diseases have a clear genetic link. While the exact transmission of allergies has not been precisely defined, medical research has demonstrated a strong familial relationship. Allergic parents tend to have allergic children. It makes sense that allergic asthma follows the same pattern. In fact the greatest predictor of childhood asthma is not IgE levels or any other specific allergy skin or blood test; it’s maternal asthma.

IgE-mediated allergic disease can manifest with a variety of presentations. I always ask my patients if anyone in their immediate family — parents, sisters, brothers, aunts, uncles, grandparents, and don’t forget the patient’s own children — has allergies. You sometimes have to give them a nudge by specifically mentioning sinus disease, skin rashes, asthma or allergy to Penicillin. Each of these are indicators of IgE-mediated disease in the family.

I have found the link to be so strong, in fact, that when a patient presents to me with asthma and no family history of allergy, I have doubts. If they had no immediate relatives with allergy, I perform an extra careful search for a non-allergic source for their respiratory symptoms. Of course, I still investigate the allergy angle for the sake of completeness and the possibility that their family members have not been properly diagnosed. But if the family history is truly allergy-free, there is generally another source for the patient’s symptoms, such as Alpha 1 antitrypsin deficiency — an enzyme deficiency that can mimic asthma and bronchitis.

Patients often ask, “My mother (or father) has a specific food or drug allergy, do I need to avoid that product?” The patient has no symptoms but the parent has a terrible reaction to a food or medicine. This is tricky. My advice is to be vigilant! We are not identical replicas of either of our parents but it is wise to be on the alert for any symptoms of allergy to parents’ severe triggers and to avoid the offender at the first hint of a symptom. This recommendation is consistent with my frequently-lectured theme to medical students and patients alike: allergic sensitization occurs after repeated exposure. Sometimes it takes several exposures before the body’s IgE response erupts in a clinical reaction.

We can’t escape our genetics, but we can limit or avoid potential allergen exposures. This holiday season of Christmas, Hanukah and Kwanzaa, when surrounded by family, it might be a good idea to ask around and complete your own Allergy Family History!

Dr. Dean Mitchell

Thanksgiving Advice for Your Allergy Patients

Both pets and foods can cause problems for allergy sufferers at Thanksgiving.

Thanksgiving is a wonderful holiday for most Americans. Families get together to celebrate each other’s company, watch football, and enjoy some delicious turkey, stuffing and a smorgasboard of trimmings. Sadly, I’ve noticed that the holiday raises several concerns for patients in my allergy practice.

For one thing, patients who are highly sensitive to cats or dogs are usually apprehensive of spending Thanksgiving at the homes of their pet-owning relatives. This makes for an uncomfortable situation: do they suffer through the dinner sneezing and wheezing, do they insult the host by declining the invitation, or do they ask that the pet — often considered a family member in it’s own right — be put away during the visit? None of these options are ideal. 

I have found that the best chance of a successful holidy for pet-allergic patients lies in having a solid plan. I strongly recommend that plan begin with the use of over-the-counter Nasalcrom twice per day for at least a week before the pet exposure. Nasalcrom is a mast cell stabilizer and it must be initiated in advance for optimal results. For Thanksgiving Day, I recommend they take a long-acting antihistamine such as Fenofexitidine for acute protection. Additional recommendations for asthmatics include preparing ahead with maximum doses of steroid inhalers leading up to the day, and use of their rescue inhaler, if separate, an hour prior to entering the home. I prefer to maintain asthmatics on an inhaler with a combined corticosteroid and beta-agonist, such as Dulera or  Advair.

Of course, planning far ahead provides the very best chance for a happy holiday for pet-allergic patients. The most effective strategy includes treatment with sublingual allergy drops, which build up their immunity to the pet allergens and significantly minimizes symptoms. I once had a patient who refused to visit her mother-in-law’s home for years because the mother-in-law had three cats and the patient became ill upon entering the home. As you can imagine, this led to a lot of family tension at holiday time. I treated the patient with sublingual drops for cat dander and her symptoms, and the family tensions along with them, completely abated. The patient was extremely happy but her husband was even happier!

Drops can take up to 12 weeks to begin taking effect — though usually much less — so it’s probably too late for them this Thanksgiving. However, Christmas, Hanukah and Kwanza are right around the corner so starting patients on an allergy drop treatment now is quite appropriate. 

Food allergies represent another potential point of holiday anxiety. The elaborate Thanksgiving dinner, with all kinds of stuffings and side dishes, may look like a veritable mine field for a patient with significant food allergies. Patients need to be proactive about contacting the host regarding specific food allergies and requesting appropriate exclusions and/or, at the very least, labeling of dishes. A severe food allergic reaction can put a real damper on the holiday spirit for everyone! Of course it is always important to remind your severely food-allergic patients to carry their epinephrine injector with them everywhere in case of emergency. This is especially critical in the midst of festive gatherings where there is likely to be a plethora of offerings.

While many food allergies are clear-cut, making avoidance do-able if not exactly easy, you must always be prepared to play detective — especially during the holiday season when special situations are the norm. My most interesting Thanksgiving allergy story was that of a patient who developed hives and swelling two Thankgivings in a row. I was intrigued because she had no known food allergies and she said she ate turkey the rest of the year without reaction. I performed extensive food allergy testing and all results came back negative. Upon review of her chart, I noticed that she had a history of allergic reaction to Cephalosporins. After some research, I discovered that turkeys are often fed antibiotics on the farm. Obviously, this supersensitive patient was triggered by exposure to the antibiotics consumed by the fresh turkey. The deli turkey she ate during the year was so processed that any antibiotic proteins it contained were likely rendered into a form no longer recognizable to the body as the original antigen.

There you have a few of my own experiences in treating allergy patients during the Thanksgiving holiday. I would love to hear any unusual cases you’ve encountered or answer any questions you have. If there’s a chance that I can help make other allergy patients’ Thanksgivings more comfortable, I am up to the challenge!

Dr. Dean Mitchell

Humidity and Mold: A Potent Combination to Set off Allergies

Mold i is common in perpetually damp areas, such as this shower stall.

It’s been hot and humid this summer, especially along the east coast. This is the time of year that most allergists take their vacations because it is the dormant season for so many trees, grasses, and weeds. This SHOULD be a good period for allergy sufferers as well. But there is a segment of patients who still battle symptoms: mold allergy sufferers.

Mold allergens are abundant in the autumn when leaves on the ground spew off the decaying mold (as I mentioned in a previous post which you can read here.) Mold doesn’t mind the summer either, especially in humid environments. In fact, mold can be a real problem indoors during this time. If your home smells damp inside, you may be at risk for mold exposure. A recent article published in The Journal of Allergy and Clinical Immunology (2013;132:1099-1110) titled “Association of Indoor Dampness and Molds with Rhinitis Risk: A Systemic Review and Meta-Analysis,” supports the theory that that mold inside the home strongly influences allergic rhinitis flare-ups. Interestingly, the strongest predictor of mold exposure was the smell of mold in the home!

A few months ago I had lunch with Bill Sothern, a true mold sleuth. Bill’s company, Microecologies, visited New Orleans just after Hurricane Katrina to help home-owners deal with the mold catastrophe resulting from the hurricane. More recently he was involved in helping victims of Hurricane Sandy in the New York, New Jersey and Connecticut area. I learned from Bill that you can’t ignore the seriousness repercussions of a mold problem. The insidious symptoms can range from classic allergy symptoms of nasal congestion, eye irritation, and asthma, to headaches, fatigue and more serious neurological complications. If you suspect mold in your apartment or home, you should contact a reputable company to investigate. At a basic level mold is differentiated by color: Green mold is highly allergenic, while black mold is highly toxic.

A few key tips for management of potentially moldy situations:

• Keep the humidity down by using air-conditioning when possible; mold hates dry and cold environments
• Crack open a window for a few hours to bring in some outside air; indoor air is 10x more contaminated than outdoor air
• Sanitize bathrooms frequently as they can be prone to mold growth

If you think you’re allergic to molds, ask your doctor to perform environmental allergy test that includes specific mold allergens. The good news is that, in conjunction with mold eradication efforts, allergy immunotherapy can be very effective at keeping symptoms at bay.

– Dr. Dean Mitchell

Taking the Sting out of Insect Allergy: When to Test, When to Treat.

Bee stings can cause severe allergic reactions.

Before food allergies became such a big problem, the specialty of allergy was best known for caring for patients suffering from reactions to venomous insect stings. I remember when I was a teenager, my mom was stung by a bee. She called our local general practitioner who told her on the phone “if you are still breathing you’ll be fine.”

I think that advice was a little cavalier. She was lucky because in that case he was right. But he should not have brushed her off without knowing for sure.

There are some very specific guidelines regarding testing and treating patients, whether children or adults, who have suspected allergy to bee, wasp, hornet or yellow jacket stings. The protocol starts with acquiring an accurate history including exact symptoms and signs associated with the sting. Any patient with a history of anaphylaxis to a sting should be tested by an allergist. The combination of the patient’s skin testing or blood testing plus the symptoms will determine if allergy immunotherapy is required.

Getting stung with venom hurts… period. However, once a patient calms down it’s important to ask what symptoms they are experiencing aside from the expected pain at the site. A local reaction of redness and swelling does not require any further evaluation. This is a normal reaction due to the toxins in the insect’s venom causing inflammation. A simple ice pack and some topical cortisone provide the fastest route to relief. On the other hand, a systemic reaction — or anaphylaxis — is cause for serious concern. Anaphylaxis to any allergen can start with a cutaneous reaction like urticaria or generalized pruritus. This might not appear alarming at first, but it is a warning sign that the sting is no longer localized and has spread to the other areas of the body. Other examples of the first sign of systemic spread are GI symptoms, cough, and general sense of feeling “not quite right.”

I would recommend to any doctor in his office, urgent care center or emergency room to give serious consideration to immediately using intramuscular epinephrine 0.3 ml into the anterolateral thigh to treat at the first sign of systemic reaction. I see many patients that are inadequately treated with just Benadryl for an urticarial reaction to a sting. This may be a grave mistake. It is not possible to predict which patients will proceed to further other organ involvement from the systemic spread of the sting reaction. Dyspnea, wheezing, heart palpitations or hypotension may come next. Those symptoms mean the anaphylactic reaction is progressing and at that point it may become much harder to treat. Any patient with systemic symptoms of the skin, respiratory tract, gastrointestinal tract or cardiovascular system should be aggressively treated with epinephrine and monitored in a hospital setting; it is much better to be safe than sorry.

Allergy testing should be performed on every patient with a history of anaphylactic reaction. Referral to an allergist experienced in evaluating these type of reactions is required. Venoms that are typically tested include: honeybees, wasps, hornets and yellow jackets.

Allergy treatment guidelines include the recommendation for every patient with a history of insect sting-induced anaphylaxis to carry an epinephrine injector. In addition, any child who has had a systemic reaction to a sting, other than simple urticaria, and tests positive to venom should receive allergy injection immunotherapy. The guidelines differ slightly for adults in that injection immunotherapy is indicated for any systemic or anaphylactic sign or symptom including urticaria. Subcutaneous allergy injections are 98% effective in preventing a severe reoccurrence of anaphylaxis— very good odds!

You are sure to see some patients this summer coming in after camping or playing in the park and complaining of insect sting reaction. Keep these facts on hand and stay prepared to point your patients in the right direction for proper diagnosis and treatment!

– Dr. Dean Mitchell

Drug Allergy: Essentials to Recognize in your Practice, Part 1

Miley Cyrus was reportedly hospitalized for a drug allergic reaction. Though I don’t know the facts of her case, I do know that drug allergy is probably over-reported by patients and possibly under-diagnosed by physicians. Confused? Let me explain.

An allergic reaction to a drug happens by the same mechanism as all other allergic reactions. It occurs when the hapten, the allergenic component of the drug, induces an immune reaction. This immune response can take place as any one of the four classic Gel-Coombs types of immune reactions. It is important to understand this concept because patient presentation can differ if it is an immediate IgE hypersensitivity reaction versus a delayed type reaction. The classic example is true penicillin allergy. A patient presents with a sore throat with white patches on the tonsils and is diagnosed with Strep pharyngitis. He is given a prescription for penicillin – which he has taken before without a problem – and on his first or second dose develops a urticarial rash and wheezing. This is an immediate type IgE immune reaction. The patient should be taken off the penicillin because continuing the antibiotic would potentially lead to life-threatening anaphylaxis. If this patient came to your office several years later with an infectious process, it would clearly be important to choose a non-penicillin-based antibiotic.

This patient’s case is straightforward. But many patients give a nebulous history of a penicillin-allergic reaction. Typically they say, “I was told as a child by my mother I was allergic to penicillin” or, “I may have had some type of rash, but no one really remembers.” Often what actually happened was that the child had a typical rash-causing viral infection. The parent took the child to the doctor before the viral rash developed, and he put the patient on penicillin for presumed bacterial pharyngitis or otitis. When the inevitable rash appeared, the antibiotic was blamed. The problem with this common scenario is that penicillin and its derivatives are safe, useful, and inexpensive, and they are often the best choice for first-line antibiotics. Lacking a clear history, but possessing the patient’s report of “allergy,” you feel obligated to avoid the penicillins.

The other problem with the penicillin allergy diagnosis is the 10% incidence of cephalosporin allergy in true penicillin-allergic patients. As a result, many doctors refuse to prescribe cephalosporins in reportedly penicillin-allergic patients. This is the conundrum in private practice: patients over-diagnose themselves with penicillin allergy and we as physicians are left with limited antibiotic choices despite the fact that many of these patients are not truly allergic.

The signs of an immediate allergic reaction to any drug are: urticarial (hives), angioedema (swelling), dyspnea (shortness of breath) and gastrointestinal distress (vomiting or bloody diarrhea). You may see just one symptom or a combination, which can indicate the potential for a dangerous drug-allergic reaction. I recommend that you carefully document the patient’s history of drug reaction(s) to ensure that true drug allergy is identified but he or she is not erroneously labeled “penicillin-allergic.” For definitive diagnosis, talk to your AllerVision Allergy Care Consultant about the Pre-Pen test for penicillin allergy.

In part 2 of this series I will discuss the serious delayed reactions that occur with different drug allergies.

– Dr. Dean Mitchell

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…

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