Food Protein-Induced Enterocolitis Syndrome

Food AllergyThe most common type of food allergy is an “immediate hypersensitivity” reaction (i.e., Type I reaction), where the symptoms usually begin within a few minutes of exposure to the offending food.  These reactions are mediated by an antibody called IgE which interacts with the protein (i.e., antigen, allergen) in the food.  This interaction causes a release of chemicals which are responsible for the undesirable allergic symptoms.  The most common foods that cause these types of reactions are nuts and shellfish, though any food can theoretically trigger IgE.

Food Protein-Induced Enterocolitis Syndrome (FPIES), though not as common, can also cause serious and potentially life-threatening adverse effects.  IgE is not involved in these reactions, because FPIES is likely to be caused by a “cell-mediated hypersensitivity” reaction (i.e., Type IV reaction), where a specific type of white blood cell called a T-lymphocyte (i.e., T-cell) is thought to play a role.

Clinically, the most distinguishing feature of FPIES is that the symptoms typically begin a few hours after the ingestion of the food.  Though it can affect people at any age, it most commonly involves infants and young children.

50 to 60% of patients with FPIES have a family history of allergic disorders such as asthma, hay fever (i.e., allergic rhinitis) or eczema (i.e., atopic dermatitis) and approximately 20% have a family history of other food allergies.

Although any food can be a trigger for FPIES, the most common culprits are milk, soy, and grains.  Breast milk is not known to be a trigger and most infants develop symptoms when they are first introduced to formula or solid food.

Symptoms of FPIES (may include any or all of the following):

  1. Recurrent vomiting
  2. Diarrhea (occasionally mixed with blood)
  3. Dehydration
  4. Lethargy
  5. Failure to thrive
  6. Poor growth
  7. Shock-like symptoms – low blood pressure, pale and clammy skin; shallow fast breathing, weakness, dizziness, fainting, etc.

Note:  Unlike traditional IgE-mediated allergies, FPIES reactions do not manifest with itching, hives, swelling, coughing, and/or wheezing.

Diagnosis and Testing of FPIES

FPIES is occasionally mistaken for a bacterial or viral infection.  Although it is a type of allergy, prick skin tests and blood tests are not helpful in the detection of this condition.  The diagnosis primarily rests on a detailed history of ingestion of specific foods, nature and severity of the symptoms in conjunction with their temporal relationship with exposure, and a detailed physical examination.  Rarely oral food challenges under controlled conditions and clinical supervision are necessary to confirm the diagnosis.

Atopy patch testing is being studied for its effectiveness in diagnosing FPIES, as well as predicting if the problem food is no longer a trigger.  At this time, however, it is not considered a valid test to make the diagnosis.

Management of FPIES

The only option in the management of FPIES is strict avoidance of the triggering food(s).  A severe reaction might necessitate emergent intravenous fluids and rarely corticosteroid agents to control inflammation in the intestines. Occasionally, children may require hospitalization if the symptoms are very severe.

Epinephrine is usually not helpful in the treatment of FPIES and is not routinely prescribed, since this condition is a non-IgE-mediated reaction.

Most children with sensitivity to milk and soy can be well managed by switching to hypoallergenic formulas, such as a casein hydrolysate or amino acid based elemental formulas.  Many children sensitive to cereal grains can tolerate yellow fruits and vegetable based age-appropriate foods.  New foods are usually introduced very slowly, one food at a time, for an extended period of time per food.  In protracted cases, dietary advice from a certified nutritionist can be very helpful.

Prognosis of FPIES

In most instances, FPIES resolves spontaneously with time.  The affected children need to be closely monitored by a board certified allergist to determine if the condition has resolved.

With proper medical care and a personalized dietary plan to ensure proper nutrition, children with FPIES usually grow and develop normally.

We Can Help You

The board certified allergy doctors at Black & Kletz Allergy will promptly answer any questions you may have regarding FPIES or any related disorders.  Our allergists have been diagnosing and treating FPIES and other food allergies in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  We have 3 convenient locations in the 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 up-to-date diagnostic and treatment modalities in the field of allergy, asthma, and immunology.

Recurrent Infections – Are They Due to Allergies?

Recurrent InfectionsRecurrent infections occur in many individuals in the U.S., as well as around the world.  In the U.S., malnutrition is not a common cause as it is in many undeveloped third-world countries.  Parasitic infections are also not very common in the U.S. unless an individual travels to a developing country, consumes uncooked meat/fish, drinks tainted water, or has an immune deficiency.  The most common types of infections found in the U.S. are numerous and include sinus infections, pneumonias, bronchial infections (i.e., bronchitis), skin infections (e.g., cellulitis, boils, abscesses), ear infections, throat infections, eye infections, gastrointestinal infections, urinary tract infections, and surgical site infections.  Nosocomial infections are a subset of infections specific to those infections that are acquired in a hospital setting.

The causative agents of most infections include bacteria, viruses, parasites, fungi, and prions.  These microbes or infectious agents can be transmitted in many ways such as person to person, mother to child, animal to person, and by food contamination.  Infections can be spread by direct contact, indirect contact, bug bites, and food contamination.

What about allergies?  Can they cause infections?  The answer is that having allergies predisposes an individual to the development of some types of infections.  The typical types of infections found more in allergic individuals may include sinus infections, ear infections, bronchitis, and pneumonia.  As a caveat to this, people with immune problems (i.e., immunodeficiencies) are more likely to develop infections.  In fact, most immunodeficiencies are found because the individual complains of recurrent infections.  People with immunodeficiencies can be stricken with infections from bacteria, viruses, fungi, and/or parasites.  These immune defects may involve B cells, T cells, NK cells (i.e., natural killer cells), phagocytic cells, and/or complement deficiencies.  The cells mentioned above are types of white blood cells in one’s body. Immunodeficiencies can be hereditary (i.e., genetic) or acquired (i.e., developed as a result of diseases, cancers, infections, malnutrition, or side effects of medications)

Some examples of hereditary immunodeficiencies include:

  1. B cell deficiencies – selective IgA deficiency, common variable immunodeficiency (CVID), X-linked agammaglobulinemia (i.e., Bruton’s agammaglobulinemia
  2. T cell deficiencies – DiGeorge syndrome, ataxia telangiectasia, Bloom’s syndrome, hyper IgE syndrome (Job’s syndrome), cartilage-hair hypoplasia, Wiskott Aldrich syndrome, X-linked lymphoproliferative syndromes, immunodeficiency-centromeric instability-facial anomalies syndrome (ICF syndrome), chromosome 22q11.2 deletion syndrome, candidiasis familial chronic mucocutaneous, dyskeratosis congenita, immunodysregulation, polyendocrinopathy and enteropathy X-linked (IPEX syndrome), hepatic venoocclusive disease with immunodeficiency, Schimke immunoosseous dysplasia
  3. NK cell deficiencies – classical NK cell deficiency (CNKD), functional NK cell deficiency (FNKD)
  4. Combined immunodeficiencies – severe combined immunodeficiency (SCID), X-linked hyper-IgM syndrome
  5. Phagocytic disorders – Chediak-Higashi syndrome, leukocyte adhesion deficiency, chronic granulomatous disease
  6. Complement system deficiencies – C1, C2, C3, C4, C5, C6, C7, C8, or C9 deficiency, properdin deficiency, mannose-binding lectin deficiency, factor B deficiency, factor D deficiency

Some examples of acquired immunodeficiencies include acquired immunodeficiency syndrome (AIDS), severe acute respiratory syndrome (SARS), cancers of the immune system (e.g., leukemia, multiple myeloma), and immune complex diseases (e.g., viral hepatitis).

In summary, many individuals suffer from recurrent infections and many can be attributed to allergy and/or immunology problems.  Allergic rhinitis, asthma, and immune disorders predispose individuals to the increase risk of various types of infections.  The allergists at Black & Kletz Allergy have been diagnosing and treating both adults and children with all types of infections for many decades in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We are board certified in both adult and pediatric allergy and immunology.  If you or someone you know suffers from recurrent infections (e.g., sinus, ears, lungs, skin), please call us to make an appointment at one of our 3 convenient offices.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of the 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 and Northern Virginia community for over 50 years for our exceptional services for the diagnosis and treatment of allergic, asthmatic, and immunological conditions.

Eosinophilic Esophagitis

Eosinophilic EsophagitisDefinition:

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition caused by the abnormal accumulation of eosinophils (a type of white blood cell) in the lining of the tube carrying food from the throat to the stomach (i.e., esophagus).

Cause:

EoE is a relatively newly discovered condition and is being diagnosed with increasing frequency in the past decade in all age groups.  Though the exact cause of the condition is still being investigated, food and environmental allergies are suspected to play a role as it is often associated with other atopic disorders like seasonal allergies (i.e., allergic rhinitis), asthma, and eczema (i.e., atopic dermatitis).  Both genetic and environmental factors are theorized to contribute to this condition.

Mechanism:

Eosinophils release various proteins that cause damage to the structure of the esophagus resulting in ridges, furrows, scarring, and narrowing of the lumen of the tube.

Symptoms:

Children:

  1. Irritability
  2. Feeding difficulties
  3. Failure to thrive
  4. Vomiting
  5. Abdominal pain

Adults:

  1. Difficulty in swallowing (particularly solid foods)
  2. Heartburn/indigestion
  3. Pain or discomfort of the chest
  4. Abdominal pain in the upper abdomen

Diagnosis:

  1. Upper gastrointestinal endoscopy and biopsy: A flexible tube with a light source and a tiny camera (i.e., endoscope) is passed through the mouth down through the esophagus and the lining of the esophagus is closely examined.  A small piece of the lining is biopsied and examined under a microscope.  Accumulation of eosinophils in the lining of the esophagus confirms of the diagnosis of EoE.
  2. Skin prick tests and/or blood tests to foods in order to rule out food allergies as a cause. This is often coupled with a food elimination diet.
  3. Skin patch tests in order to detect delayed hypersensitivity to foods.
  4. Skin tests to environmental allergens such as pollens, especially when the symptoms of EoE exhibit a seasonal pattern.

Management:

  1. Restriction of certain specific foods in the diet based on skin prick and/or patch test results.
  2. Empiric elimination diets starting with dairy, wheat, eggs, soy, peanuts, tree nuts, fish, and shellfish (preferably under the guidance of a dietician) and gradually reintroducing one food at a time while closely monitoring the symptoms and follow-up biopsies.
  3. Medications: There are currently no FDA approved medications specific to EoE, but the following medications are commonly employed in the treatment of the condition refractive to dietary management.
  4. In a subset of individuals with EoE called Proton pump inhibitor-responsive esophageal eosinophilia (i.e., PPI-REE), medications called proton pump inhibitors (i.e., PPI’s) are used to reduce acid secretion in the stomach. Medications in this category [e.g., omeprazole (Prilosec); esomeprazole (Nexium)] can greatly help in relieving the symptoms.
  5. Topical corticosteroids which are usually utilized in inhalers to treat asthma [e.g., fluticasone (Flovent); budesonide (Pulmicort)] can also be helpful in EoE when ingested in a slurry form. They can control the structural damage to the esophagus due to their anti-inflammatory properties.
  6. When the disease is more severe and non-responsive to topical medications, systemic corticosteroids (e.g., prednisone, prednisolone, methylprednisolone) may be needed for a short duration.
  7. Newer anti-inflammatory drugs and biologicals are being researched in clinical trials at this time and may be available in the near future.
  8. In cases of severe narrowing of the esophagus, a procedure to dilate the esophagus by breaking up the strictures may help in relieving swallowing difficulties.

EoE is a complex immune system disorder with a chronic and relapsing course that has no known cure at this time.  Optimal management of the condition requires coordinated care by an experience board certified allergist, gastroenterologist, and nutritionist/dietician.

The board certified allergists at Black & Kletz Allergy will readily respond to your needs for further information and services in dealing with EoE and other allergic and immunologic disorders.  The allergy specialists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We offer on-site parking at all of our offices and our 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 make an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond to your inquiry within 24 hours by the next business day.  Black & Kletz Allergy treats both children and adults and we strive to provide the best and most current diagnostic and treatment modalities in the Washington, DC metro area, as we have done for more than 50 years.

Ragweed Allergies

Ragweed AllergyIt is August in the Washington, DC metropolitan area and to many allergy sufferers, that means ragweed pollen is in the air.  Ragweed is a flowering plant that releases its pollen into the air in the Washington, DC, Northern Virginia, and Maryland metro area usually beginning in mid-August and lasting until the end of October when the first frost occurs.  Recent studies show that with the rising temperatures and rising carbon dioxide (CO) levels, the ragweed season is now longer and may begin as early as early August.  Ragweed pollen is a major allergen to many allergic individuals that suffer from hay fever (i.e., allergic rhinitis) and is the number one cause of pollen-induced allergic rhinitis in North America.  Each ragweed plant can generate approximately 1 billion grains of ragweed pollen each season.  The ragweed pollen, like other pollens, is transported by the wind.  The wind causes the ragweed to become airborne for days which provides individuals an easy way to become exposed and thus sensitized to the ragweed pollen.  Ragweed pollen, like other pollens, can travel hundreds of miles due to its light weight.  The ragweed pollen count is lowest in the early morning and tends to peak in the midday.  Once sensitized, a person may exhibit the typical hay fever symptoms when exposed during the ragweed season.

What are the symptoms of ragweed allergy?

The classic symptoms of ragweed allergy may include all or any of the following:  runny nose, itchy nose, sneezing, post-nasal drip, nasal congestion, itchy throat, snoring, itchy ears, clogged ears, itchy eyes, watery eyes, red eyes, puffy eyes, sinus congestion, sinus headaches, fatigue, wheezing, coughing, chest tightness, and/or shortness of breath.  Complications of ragweed allergies may include sinus infections, asthma exacerbations, ear infections, nasal polyps, Eustachian tube dysfunction, inability to concentrate, and sleep disturbances.

What can be done to avoid exposure to ragweed pollen?

Unfortunately, it is almost impossible to avoid exposure to ragweed pollen if you live in the Washington, DC metro area.  In fact, it is almost impossible to avoid no matter where you live in the U.S.  That being said, there are some measures that can be followed to minimize one’s exposure to ragweed pollen.  They are as follows:

  1. Keep the windows and doors closed in your automobiles and home.
  2. Stay indoors as much as possible during the ragweed season, especially from the late morning through the late afternoon when the ragweed pollen count is at its highest.
  3. Check the daily pollen count by clicking Today’s Pollen Count on our website above.
  4. Use air conditioning in both your automobiles and home.
  5. Use and change the air filters in your home and automobiles.
  6. When coming inside after being outdoors for a prolonged period of time, change your clothes.
  7. Take a shower before going to sleep at night to remove pollen.
  8. Do not hang your clothes to dry outdoors on a clothes line, as it will collect pollen.
  9. Wash your pet if the come indoors after a long period of time, as their fur acts as a carrier for pollen.
  10. Use a HEPA filter in each room of your home, or at least the rooms that you use most often

What medications can be used to alleviate symptoms?

There are a wide variety of over the counter (OTC) medications that can be utilized to help treat the symptoms of allergic rhinitis caused by ragweed.  Using nasal irrigation with saline can be very beneficial for most individuals to help reduce the nasal symptoms of ragweed allergy.  Oral antihistamines, nasal corticosteroids, nasal antihistamines, oral decongestants, anticholinergic agents, eye drops, and/or leukotriene antagonists are frequently used by board certified allergists like the ones at Black & Kletz Allergy to help prevent and manage hay fever symptoms.  For asthma symptoms that are caused by ragweed, a variety of medications are commonly used.  Some of these include inhaled corticosteroids, long-acting beta-agonists (in combination with inhaled corticosteroids), leukotriene antagonists, inhaled beta-adrenergic agonists, oral beta-adrenergic agonists, and xanthine derivatives.  Xolair (i.e., (omalizumab) and Nucala (i.e., mepolizumab) are injectable medications that are used to treat more difficult cases of perennial asthma, where the asthma is more chronic.

Are allergy shots helpful?

Absolutely yes.  Allergy shots (i.e., allergy immunotherapy, allergy injections, allergy desensitization) are very helpful.  Allergy shots have been around for more than 100 years in the U.S.  They are generally given to individuals of any age above the age of 2, and they can be continued in pregnant individuals, as long as it is approved by the individual’s Ob/Gyn doctor.  They are effective in 80-85% of individuals and the average length of time on allergy shots is 3-5 years.  They work by making the individual tolerant to whatever is put into their allergy serum (e.g., ragweed, trees, grasses, dust mites, molds, cats, dogs).

Where can I get help with my allergies?

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating ragweed allergy for more than 50 years in the Washington, DC, Northern, VA, and Maryland metropolitan area.  Black & Kletz Allergy also treats allergies to other environmental triggers (e.g., trees, grasses, dust mites, cats, dogs, horses, rodents, cockroaches), medications, foods, insect stings, poison ivy, poison sumac, and poison oak.  We also treat hives (i.e., urticaria), swelling episodes (i.e., angioedema), generalized itching (i.e., pruritus), immunological disorders, mammalian meat allergy, sinus disorders (e.g., sinus infections), eosinophilic esophagitis, eczema (i.e., atopic dermatitis), contact dermatitis, nasal polyps, latex allergies, and anaphylaxis.

Black & Kletz Allergy has 3 convenient office locations:  Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer on-site parking.  The Washington, DC and McLean, VA locations are Metro accessible and there is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To make an appointment, please call us or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy is dedicated to providing quality cutting edge allergy, asthma, and immunologic care to the residents and visitors of the Washington, DC metro area, as we have done for more than a half century.

Common Allergens in Sunscreen

sunscreenUnderstanding Sunscreen Sensitivities

Contact dermatitis is a rash on your skin due to contact with an irritating substance, such as those used in common sunscreen formulas. Your skin could be irritated or having an allergic reaction which is more prominent on areas that have direct exposure to the sun, such as your face or where clothing isn’t protecting you. This is a known as photo-contact dermatitis and may also be a reaction to preservatives or fragrances used.

Those Prone to Allergies

Certain groups of people or individuals are more prone to developing an allergy to sunscreen. Females are more affected particularly because they are more prone to using cosmetics that can contain potentially irritating substances. Those with sun-damaged skin, sunscreen being applied to areas of damaged skin and people who work outdoors on a regular basis such as construction workers. The American Academy of Dermatology advises that everyone wear sunscreen because one in five Americans will eventually develop skin cancer due to the sun’s harmful UV rays.

Understanding How Sunscreen Works

There are two ways sunscreen works to protect your skin. The chemical absorbers in sunscreen absorb the energy from the sun as it hits your skin and turns it into less dangerous and damaging radiation. Physical blockers reflect the sun’s rays to prevent radiation from being absorbed and are commonly found in products used by people who spend significant time at the beach.

Chemicals That Can Cause Allergies

Everyone has a different reaction to chemicals and to the active ingredients found in many sunscreen products. It can be hard to pinpoint which ingredient is causing a reaction since some have multiple active ingredients. These are some of the ingredients found in many popular sunscreen products:

  • Benzophenone – This has been used in sunscreen for quite some time and is one of the most common irritants in sunscreen formulas. Other names for it are eusolex, methanone, and diphenyl ketone.
  • Dibenzoylmethane – This has been commonly used in sunscreen since 1997 in the United States and acts as a chemical absorber.
  • Octocrylene – This is a newer chemical used in many sunscreen products and has the potential to cause contact dermatitis for individuals who have sensitive skin. It is typically used to enhance a product’s scent.

It’s important to protect your skin from the harmful rays of the sun, but experiencing an allergic reaction is less than desirable and can be very serious. Be careful when selecting sunscreen, and maybe even consider the answer to the question, “What is the best all natural sunscreen?” to avoid those common allergenic chemicals.

bu Sunscreen | Sunscreen and UV Apparel Thanks to our friends and contributors from Bu Screen for their insight into common allergens in sunscreen.

Summer Allergies and Asthma

Allergy SeasonAllergens (i.e., antigens) that are commonly found in the Washington, DC, Northern Virginia, and Maryland metropolitan area in the Summer may include:  pollens, molds, dust mites, pets, cockroaches, stinging insects (e.g., bees, wasps, yellow jackets, white-faced hornets, yellow-faced hornets), and non-stinging insects (e.g., mosquitoes, gnats).

Non-allergens (i.e., irritants) that cause allergy-like symptoms and/or asthma, that are found in the Summer in the Washington, DC metro area may include:  smog, smoke, ozone, diesel fuel, dust particulates, and automobile exhaust.

Grass pollens are more prevalent in the early Summer, whereas ragweed pollen generally begins to pollinate in the middle of August and typically ends in late October with the arrival of the first frost.  There are also small amounts of tree pollens that linger in the air during the beginning of the Summer in the Washington, DC metro area, although characteristically, tree pollens wreak havoc mostly in the Spring.

Molds are omnipresent in the greater Washington, DC metropolitan area since Washington, DC was built on a swamp.  In the Summer, there is higher humidity, along with warmer temperatures which provides the perfect condition for mold growth.  Molds are also found indoors and tend to gravitate to places such as basements, kitchens, and bathrooms where moisture may be worse.

Dust mites (e.g., Dermatophagoides farinaeDermatophagoides pteronyssinus) are microscopic bugs that tend to live in carpeting, fabrics, and bedding.  They live off of dead skin that naturally sloughs off of humans and animals.  They will also eat molds.  Dust mites reach their peak concentrations during the Summer and thrive in the warm, humid environment that Washington, DC is famous for in the Summer.

Cats, dogs, horses, and furry pets (i.e., hamsters, guinea pigs, rats, mice, ferrets) are a source of allergens throughout the year, because they are generally kept indoors, except for horses.  As the weather warms up, people tend to go horseback riding more often, so people tend to complain of allergies to horses more often during the warmer months of Summer.  In addition to the actual pet allergy itself, cats and dogs often transfer pollens on their furry coats from the outside to the inside of one’s home which may add to the misery of a particular allergic individual.

Cockroaches are very common in homes, restaurants, and stores especially in inner city locations such as Washington, DC.  They are highly allergenic and are responsible for exacerbating asthma, particularly in asthmatic children who live in the inner cities.

Stinging insects are also more common in the Summer.  Bees, wasps, yellow jackets, white-faces hornets, and yellow-faced hornets are always around during this time of year.  They tend to like being around food and tend to be found quite often at picnic grounds, barbeques, swimming pools.  They also are found near gardens, lawns, and parks.  Note that stinging insects can be anywhere and sensitive individuals should always practice avoidance measures and carry an epinephrine auto-injector (e.g., EpiPen, Auvi-Q, Adrenaclick), if prescribed by an allergist such as the board certified allergists at Black & Kletz Allergy.  If an individual uses their epinephrine auto-injector, they should immediately go to the closest emergency room.  Life-threatening anaphylactic reactions (i.e., anaphylaxis) to stinging insects do occur and anyone who has had any type of systemic reaction in the past to a stinging insect should definitely see a board certified allergist for venom testing and possible venom immunotherapy (i.e. “bee shots”), since venom immunotherapy is highly effective in preventing anaphylactic reactions with future stings.

Non-stinging insects such as mosquitoes are more prevalent in the Summer and tend to migrate near standing fresh water.  Even a small puddle is enough standing water to act as a reservoir for the breeding of mosquitoes.  Most of the reactions to non-stinging insects involve a local redness and/or swelling of the skin.  There may be pain and/or itching associated with the bites.  In rarer situations, an individual may experience an anaphylactic reaction.  If this occurs it is important to use an epinephrine auto-injector and immediately go to the closest emergency room.

Non-allergens (i.e., irritants) such as smog, smoke, ozone, diesel fuel, dust particulates, and automobile exhaust also may cause allergy-like and/or asthma symptoms in many susceptible individuals.  Automobile exhaust in combination with the heat of summer and ultraviolet (UV) rays of the sun contribute greatly to increased levels of ozone and smog.  In addition to ozone and smog, dust particulates and smoke are two more non-allergic irritants that contribute to air pollution.  Air pollution is unhealthy to human life when the pollution level or air quality index (i.e., AQI) rises to above 150.  Note that the AQI ranges from 0 to 500.  AQI’s above 100 are unhealthy for certain sensitive groups of people (e.g., people with lung disease).  AQI’s above 300 are hazardous to everyone.

The board certified allergy specialists at Black & Kletz Allergy have over 50 years’ experience in the diagnosis and treatment of environmental allergies and insect sting and bite allergies.  Although these conditions may be more prevalent in the Summer, environmental allergies are a perennial problem and most sensitive individuals have year-round symptoms.  Black & Kletz Allergy specializes in both adults and children who have allergies and/or asthma.  We have 3 locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  There is on-site parking at each location and the Washington, DC and McLean offices are Metro accessible.  There is also a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.

If you would like us to help you with your allergies and/or asthma, please call us at one of our office locations that are convenient for you.  Alternatively, you can click Request an Appointment and we respond within 24 hours by the next business day.  We are here in order for us to make your Summers more enjoyable by eliminating or markedly reducing your allergy and/or asthma symptoms.

Mosquito Bite Reactions

Mosquito Bite ReactionsThe onset of summer brings with it the menace of mosquitoes.  Though we are more concerned about diseases transmitted by mosquitoes such as malaria, encephalitis, dengue fever, chikungunya, West Nile virus, yellow fever, filariasis (elephantiasis), Western equine encephalitis, Eastern equine encephalitis, Japanese encephalitis, Venezuelan equine encephalitis, St. Louis encephalitis, La Crosse encephalitis, Ross River fever, Rift Valley fever, and most recently Zika virus-related illnesses, adverse reactions to mosquito bites can be very severe in susceptible individuals.

Mosquitoes inject their saliva into the tiny blood vessels in our skin, before sucking the blood. Immunological reactions to the chemicals in the saliva of the mosquito are usually responsible for the untoward reactions.  The chemicals can also interfere with the clotting mechanism in individuals resulting in local bleeding.

Three types of reactions can occur:

  1. The most common manifestation is localized redness, swelling, and/or itching. The symptoms usually begin a few hours after the bite and usually resolve spontaneously within a few days.
  2. Blistering lesions and/or larger hives (i.e., papular urticaria), sometimes accompanied by mild fever and joint stiffness and pain, may occur and are generally more bothersome than the localized redness, swelling, and/or itching mentioned above.
  3. Very rarely mosquito bites may result in serious generalized reactions (i.e., anaphylaxis), affecting multiple organ systems.

The typical clinical course of sensitization and natural desensitization usually proceeds in five stages:

  1. People who have never been exposed to a particular species of mosquito do not develop reactions to the initial bites from such mosquitoes.
  2. Subsequent bites result in the appearance of delayed local skin reactions.
  3. After repeated bites, immediate wheals may develop.
  4. With further exposure, the delayed local reactions wane and eventually disappear, although the immediate reactions persist.
  5. People who are repeatedly exposed to bites from the same species of mosquito eventually also lose their immediate reactions.

Treatments:

  1. Application of ice and elevating the affected area can help reduce swelling and/or pain.
  2. Blisters need to be cleaned with soap and water.
  3. 1% hydrocortisone cream or ointment which can be found over-the-counter will help control inflammation. This cream or ointment may be applied twice a day for up to 1 week, as there are potential side effects of prolonged use of such steroid creams/ointments.
  4. Oral antihistamines may help relieve itching to some extent.
  5. Antibacterial medications may need to be used if the area becomes infected which is not very common.
  6. In the case of systemic reactions, carrying an epinephrine auto-injector (i.e., EpiPen, Auvi-Q, Adrenaclick) is highly recommended.

Avoidance:

  1. Mosquitoes usually breed in pools of standing water. Keeping outdoor areas free of standing water will discourage mosquito breeding.
  2. Mosquito bites occur more often from dusk to dawn. Staying indoors also is advantageous to reduce one’s exposure to mosquitoes.  Using screened windows and screened porches are helpful in reducing mosquito exposure.
  3. Wear protective clothing with long sleeves and pants. Avoid bright colors and heavy perfumes and colognes which can attract mosquitoes.
  4. Insect repellants containing DEET (i.e., N,N-diethyl-3-methyl-benzamide or N,N- diethyl-meta-toluamide) as the active ingredient are most effective. Repellants containing 10 to 25% DEET provide approximately 2 to 6 hours of protection.
  5. Some individuals can be sensitive to DEET, which may cause irritant reactions (e.g., skin rashes, itchy skin, redness of the eyes, watery eyes). Testing the insect repellant on a small area of skin before application over extensive areas is helpful in determining if it is an irritant to a particular individual.  Utilizing only the lowest effective concentration is preferable.
  6. Products containing the active ingredients picaridin, oil of lemon eucalyptus, and IR 3535 (i.e., 3-[N-Butyl-N- acetyl]-aminopropionic acid, ethyl ester or Ethyl 3-[acetyl(butyl)amino]propanoate) are also effective repellants in individuals that do not want to use DEET or react to DEET.

The board certified allergists of Black & Kletz Allergy have had over 50 years of experience dealing with mosquito bite reactions.  Black & Kletz Allergy has 3 office locations in the greater Washington, DC, Northern Virginia, and Maryland metropolitan area.  The allergy doctors at Black & Kletz Allergy diagnose and treat both adults and children with allergies (e.g., hay fever, food allergies, medication allergies), asthma, hives, swelling episodes, eczema, contact dermatitis, insect bites, bee sting allergies, sinus disease, and immunologic problems.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA and have on-site parking at each location.  The Washington, DC and McLean, VA offices are Metro accessible and there is a free shuttle that runs between our McLean, VA office and the Spring Hill metro    station on the silver line.  Please call us to make an appointment or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy has been striving to provide high quality allergy and asthma care to the residents of the Washington, DC metro area for more than a half a century and we are dedicated to continue delivering state of the art allergy and asthma care in the future.

Thunderstorms and Asthma

Thunderstorms and AsthmaA very interesting article was published in the current issue of the Journal of Allergy and Clinical Immunology in the section “Paradigms and Perspectives.”

In Melbourne, Australia, on Monday, November 21, 2016, hospitals were swamped with emergency patients affected by severe asthma exacerbation’s.  There were more than 8,500 patients from Monday night to Tuesday and 9 of them died.  Firefighters and police were called in to help physicians and paramedics respond to thousands of calls after the outside conditions caused breathing problems for its many citizens.  It caused many individuals, including those with a history of hay fever (i.e., allergic rhinitis), without a prior history of asthma, to experience breathing difficulties.  Many had severe and/or near-fatal asthma exacerbation’s.  The epidemic in Melbourne was due to a very unusual weather occurrence.  There were thunderstorms with high wind velocities and torrential rain combined with a high pollen count sending a large amount of grass pollen allergens into the air across the city.

In normal circumstances, pollen grains penetrate into the upper airways of individuals but only reach these larger airways in the lungs due to their large size.   However, it is postulated that during thunderstorms, pollen grains can rupture due to osmotic shock and release their content into the atmosphere.  As a result, the very small granules released into the air are now able to reach the lower smaller airways which then in turn induce asthma symptoms.

During the first 20 to 30 minutes of a thunderstorm, a high concentration of allergenic material released by the pollen is dispersed into the atmosphere.  People who have been previously sensitized to the pollen can experience acute and severe flare-ups of coughing, wheezing, chest tightness, and/or shortness of breath after inhaling these allergens.  This situation described above constitutes a major concern nowadays because of the ‘‘highly likely’’ increase in the frequency of heavy precipitation events, including thunderstorms, projected by climate change scenarios for future decades.

Ironically, rainfall is usually known to remove pollens from the air.  During a thunderstorm, however, dry updrafts force whole pollens into the high humidity at the cloud level, where pollens can rupture and cold downdrafts can carry pollen fragments to the ground level.  The relationship between allergen exposure, airway inflammation, and clinical symptoms is complex.  Factors other than allergens such as cold air and perhaps electrical charges of the atmosphere may also be playing a role in triggering asthma.

It is important to realize that people who previously had only hay fever symptoms are also at a higher risk for asthma during a thunderstorm.  Patients affected by pollen allergies should be aware of the danger of being outdoors during a thunderstorm in the pollen seasons.  Staying indoors with the windows closed significantly reduces the risk of asthma exacerbations.  Using inhaled asthma medications (e.g., bronchodilators, corticosteroids) at the onset of symptoms can minimize the severity of the asthma “attacks.”  Allergy shots (i.e., allergy immunotherapy, allergy injections) can also minimize or prevent asthma exacerbations caused by pollens, as well as dust mites, molds, pets, and cockroaches.

The board certified allergists at Black & Kletz Allergy located in the Washington, DC, Northern Virginia, and Maryland metropolitan area will readily answer any questions you have regarding your asthma and/or allergy symptoms.  We have 3 offices with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer on-site parking.  In addition, the Washington, DC and McLean, VA offices are accessible by Metro.  There is also a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  Please make an appointment by calling any one of our 3 offices, or alternatively, you can click Request an Appointment and we will answer you within 24 hours by the next business day.  Black & Kletz Allergy diagnoses and treats both adults and children and we are proud to serve the Washington, DC metro area residents for which we have done for more than 50 years.

Pet Allergies – What are They and What Can Be Done to Help?

Pet AllergyMore than 60% of U.S. homes have pets and about 10% of the U.S. population have pet allergies.  Most of the pets in the U.S. are cats, followed closely by dogs, but almost any animal can be a pet.  One is to be about twice as likely to be allergic to cats as to dogs.  There are more than 160 million cats and dogs considered pets in the U.S. alone.  While it is thought that short-haired cats and dogs are “hypoallergenic,” in truth, there are no hypoallergenic cats and dogs.

Individuals who are allergic to their pets generally have the same symptoms as people who have allergic rhinitis and allergic conjunctivitis to other allergens such as dust mites, molds, pollens, and, cockroaches.  These symptoms may include some or all of the following:  sneezing, runny nose, nasal congestion, itchy nose, post-nasal drip, itchy ears, clogged ears, itchy throat, itchy eyes, red eyes, watery eyes, puffy eyes, sinus congestion, sinus headaches, snoring, hives, generalized itchiness, swelling episodes, fatigue, wheezing, chest tightness, coughing, and/or shortness of breath.

It is the proteins found in the pet’s dander, urine, and saliva that act as the allergens which cause pet allergic individuals to react when exposed to pets.  In cats, the major allergenic protein is called Fel d 1.  Fel d 1 is primarily produced in cat saliva as well as in the skin itself.  Male cats produce more Fel d 1 than female cats.  Other cat allergens include Fel d 2, Fel d 3, Fel d 4, Feld 5, and Fel d 6.  Fel d 4 seems to be the 2nd most potent cat allergen after the major cat allergen which is Fel d 1.  Can f 1 and Can f 2 are the two major dog protein allergens which are found on a dog’s dander.  They are produced by the dog’s tongue tissue as well as other salivary glands.

In addition to cats and dogs, there are numerous other animals that people have as pets, some of which include birds, rabbits, ferrets, hamsters, guinea pigs, gerbils, mice, rats, spiders, snakes, lizards, turtles, fish, and horses.  In general, fish, reptiles, and amphibians as pets do not cause significant allergies to most individuals.

If you or someone you know has allergy and/or asthma symptoms when exposed to pets or has allergy and/or asthma symptoms and they live with a pet, they should seek a board certified allergist’s care to determine if they are in fact allergic to that pet.  At Black & Kletz Allergy, our board certified allergy doctors have the expertise in determining if someone has a pet allergy.  It begins with a comprehensive history and physical examination to identify any signs or symptoms that appear to be attributable to a pet allergy.  The diagnosis can be confirmed with allergy testing which can be done via blood tests or allergy skin tests, with the latter being a more sensitive testing method.

Once the diagnosis is made, our allergists will make recommendations on how to best avoid the pets as well as reduce exposure to the pet allergens, since in almost every circumstance, the person does not want to part with their pet as it is a beloved member of their family.  Black & Kletz Allergy offers many tips to pet-allergic individuals that help reduce exposure to the pet allergen proteins that cause allergic symptoms.  Allergy medications are usually prescribed in order for the individual to be able to tolerate being around the pet.  These medications may include oral antihistamines, nasal sprays, eye drops, inhalers, and/or leukotriene antagonists.  Allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization) has been found to be extremely effective in the management of pet allergies.  In addition, allergy shots may also contain other allergens such as dust mites, molds, and/or pollen, depending upon the individual’s sensitivities and his or her allergy history.  Allergy shots are effective in the treatment of allergic rhinitis in about 80-85% of the patients that take them.  The average length of treatment on allergy shots usually ranges from 3-5 years.

Black & Kletz Allergy has 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  The McLean, VA office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line.  If you suffer from pet allergies and/or asthma related to animals, as well as any other type of allergy, please call us to schedule an appointment.  Alternatively, you can click Request an Appointment and we will respond to you within 24 hours by the next business day.  Black & Kletz Allergy has been providing excellent allergy and asthma care in the Washington, DC metro area for more than 50 years and we look forward to helping you.

Grass Allergy and What Can Be Done to Help You

Grass Allergy

In the Washington, DC, Northern Virginia, and Maryland metropolitan area, grass pollinates mostly from the end of April through the end of August.  The peak grass pollen levels tend to be from May through July, however.  Grass is a very common allergen as it affects millions of individuals.

There are thousands of types (i.e., species) of grasses and many cross-react with one another.  This means that if you are allergic to a particular type of grass, then you are likely to exhibit allergic symptoms if you are exposed to another type of grass if it is within the same grass subfamily.  Pooideae is the largest subfamily of the grass family Poaceae.  These grasses are common grasses known to cause allergic rhinitis (i.e., hay fever) in sensitized individuals.  They tend to occur in temperate climates in the U.S.  Some of the grasses in this subfamily include Timothy, Red top, Sweet vernal, Orchard, Meadow fescue, Kentucky blue, and June.  They also include the common cereal grasses (e.g., rye, wheat, barley, oat).  Panicoideae, also in the grass family Poaceae, is another common grass subfamily and its’ grasses are also a common cause of allergic rhinitis.  Common grasses in this subfamily include Johnson and Bahia.  In the grass family Poaceae, subfamily Chloridoideae, the most common grass to cause allergy symptoms is Bermuda.  Bermuda grass tends to occur mostly in the southern half of the U.S. where there are warmer temperatures.

The typical allergic rhinitis symptoms that most allergic individuals suffer from may include all or some of the following:  sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, clogged ears, itchy ears, itchy eyes, watery eyes, puffy eyes, hoarseness, snoring, sinus congestion, sinus headaches, wheezing, chest tightness, shortness of breath, and coughing.  In very allergic individuals, contact with grasses may cause itchy skin and hives.  Rarely, a very grass-allergic person may develop anaphylaxis if he or she scrapes their skin on grass and it gets into the bloodstream, as is not uncommon in certain sports such as football, baseball, and soccer.

In order to manage one’s grass allergies, the following tips are recommended:

  • Avoid mowing the lawn, but if you need to mow it, wear a mask.
  • Remove your clothes after coming inside from outdoors. Take a shower to wash the pollen off of you as well as wash your clothes.
  • Keep your lawn short, as grass pollinates when the grass is tall.
  • Keep an eye on the pollen count. You check it daily by clicking Today’s Pollen Count.
  • Wash your pets when they come indoors, as their fur will transport grass pollen into your home.
  • Avoid hanging wet clothes outdoors to dry, as pollen will gather on the clothes.
  • Keep your windows and sunroofs closed in your motor vehicles.
  • Keep your doors and windows closed in your house.
  • Use over the counter allergy medications such as oral antihistamines, nasal sprays, and/or eye drops, if approved by your physician.
  • See a board certified allergist, like the ones at Black & Kletz Allergy, if your symptoms are not alleviated by over the counter medications.

The board certified allergists at Black & Kletz Allergy have expertise in diagnosing and treating grass allergies as well as other environmental allergies such as trees, weeds, dust mites, molds, cockroaches, pets, and other animals.  We diagnose and treat both children and adults.  In addition, we also see patients with a variety of other allergic/immunologic conditions such as asthma, eczema, sinus problems, hives, swelling episodes, generalized itching, food allergies, poison ivy, poison oak, poison sumac, contact dermatitis, insect sting allergies, medication allergies, eosinophilic esophagitis, hypogammaglobulinemia, and other immune disorders.

Black & Kletz Allergy has 3 convenient locations in the Washington, DC metropolitan area.  Our office locations are in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  Each office has on-site parking 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.  To make an appointment, please call our office location that is most convenient for you or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy strive to provide our patients with the highest quality allergy and asthma care in the Washington, DC and Northern Virginia metropolitan area.