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There is No Such Thing as an Allergy Test

I have been teaching medical students in my office for the past several weeks. These first year University of Arizona students have recently completed a block of studies on the immune system and are spending time in an allergy clinic to learn how memorizing a million obscure names and pathways  applies to the real world of clinical medicine.

Each student spends only half a day with us so there is not much time to impart wisdom. Since this may be their only exposure to the specialty, I have tried to come up with a few important “pearls” for them to take with them.

Here is one of those pearls: “There is no such thing as an allergy test.”

Since we spend a lot of time in our practice testing patients to find out what they are allergic to, this statement is usually greeted by the students with a polite stare as if waiting for the punch line.

First year medical students are understandably a bit nervous when introduced to the real world of doctoring for the first time. They are quite sure of one thing: They do not know very much now and that somehow, over the course of just four years, they will be expected to know practically everything. They are also quite sure that they have no idea how this miracle of knowledge transfer is supposed to happen.

So the students typically smile politely and try not to say anything that would make them look any stupider than they feel. I try to reassure them and suggest that if there ever was a time to ask stupid questions, your first few years of medical school would be it.

The assumption that somehow you should know and that surely everyone but you knows is pervasive but also foolish and can be a serious hindrance to learning. Wisdom begins when we are able to put our pride in our pocket,  acknowledge our ignorance, and ask the stupid question. The other students, contrary to your assumption,  are also quite clueless,  and certain to be relieved when you do.

Back to the point. Why is there no such thing as an allergy test and why is this so important for medical students to learn?

The answer is in the definition of allergy.

Allergy is an adverse condition and symptoms caused by immunologic sensitization and exposure to an allergen.  An allergen, almost always a protein, is the thing (food, animal, pollen, mold, etc) that your immune system decides – arguable by mistake – you need to be defended against.  The resulting production of specific antibodies that react with the allergen is called sensitization.   Without it, you are not allergic.

Sensitization is the part that we learn from an allergy test.

However, having symptoms when exposed to the allergen you are sensitive to is also part of the definition of allergy. Without symptoms, you are not allergic. No matter what the results of an allergy test say.

A diagnosis of allergy cannot be made without a careful  history. In fact, when allergy tests alone are used to make a diagnosis of allergy – which is often the case when patients ask their family doctor to order an allergy test to find out what they are allergic to – the results can be confusing and misleading and even dangerous. In my experience, this is often the case.

Inappropriate diagnosis made on the basis of allergy tests alone have led to unnecessary restriction of foods, elimination of loving pets from the home, disruptive changes at home and at school, and prescriptions for insanely expensive medications such as Epipens.

On their own, blood tests and skin tests for allergy can give falsely positive results as often as 50% of the time. That means that if an allergy test is positive for peanut, and no consideration if given to the patient’s history, there is a 50% chance that the patient is allergic to peanuts and a 50% chance that they are not.

If history is not taken into account to make the diagnosis, an allergy test is about as good as flipping a coin.

Coupled with a thorough and accurate history, however, an allergy test is an essential tool for a making a diagnosis of allergy.

The history – listening! – is the most important skill for a physician to learn. And this is why it is important for medical students to remember: “There is no such thing as an allergy test”.

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What is Blooming in Phoenix?

If you have been sneezing and your eyes and nose stinging and watering you might be asking: “My allergies are driving me crazy, what in the world is blooming this time of year?”

And like many, to find out you might google it, put in your zip code and come up with something like this from Pollen.com.

Source: Pollen.com

Source: Pollen.com

 

Source: Pollen.com

Source: Pollen.com

Seems pretty clear. Your sneezing and drippy nose is being caused by all the pollinating Ragweed, Chenopods (whatever they are), and Sagebrush in your neighborhood.

Perhaps not.

Notice in the map above that Arizona, Southern California, Utah, and Nevada all have the same pollen forecast.  All those regions are pretty much the same aren’t they?  Just like all of Arizona is the same, right?

Perhaps not.

Anyone who has taken a road trip from Phoenix to Prescott, Payson, or Flagstaff in August can tell you that the scenery, not to mention the temperature, changes dramatically as you drive north.  Gliding along on the 1-17, your car is like a time machine driving into the future. You leave the pizza oven called Phoenix with it’s scorched earth landscape and toxic ozone haze, and in two hours you’ve travelled from summer to blissful fall.  The leaves are changing, the air is clear, cool and crisp, (sweater weather) and wild grass on the hill side is swaying in the breeze (along with the ragweed, BTW ).

If you were to continue driving north, past Flagstaff, you would enter yet another ecosystem, the high desert, home to many plants not found in the low desert of South and Central Arizona or around the San Francisco Peaks.  Sagebrush for example is a huge allergy problem in the high desert surrounding Winslow and Page but has minimal presence in Phoenix. (Texas Sage, a common ornamental landscape bush, is not a member of the Sagebrush family.)

Because of the differences in elevation and temperature, the unique ecosystems of Arizona have different pollinating schedules.  Ragweed and Sagebrush may be wreaking havoc in Winslow at the same time that the poor ragweed around Phoenix is just trying to keep from drying up and blowing away.  So a pollen report showing that Ragweed and Sagebrush is high in Arizona is technically accurate but misses the mark for those living in Phoenix.

Some pollen reports seem to group all of the Southwest into the same region.  A report from a pollen counting station located in San Diego will give results that will look very strange if you happen to live in Ahwatukee, even though they are both part of the “Southwest”.

Not Ahwatukee

Not Ahwatukee

To my knowledge, the location of the pollen counting stations for Pollen.com and the weather sites are not listed on their websites.    One of the best sources for pollen levels is the American Academy of Allergy and Immunology.  AAAAI has a rigorous certification process to insure that sights are providing good information. But there is a problem for the Phoenix area.  Below is a map showing the location of certified pollen counting stations in the west.  Notice something missing?

Source: http://www.aaaai.org/global/nab-pollen-counts/western-region

Source: http://www.aaaai.org/global/nab-pollen-counts/western-region

Getting back to the question: “What is blooming in Phoenix”.   This time of year the answer is: “Not much.”

So if pollen counts in Phoenix are low, what is causing all the sneezing, drippy nose, and red, burning, watery eyes in mid August?

For many, this is the problem:

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Source: airnow.gov Phoenix 8/28/2017

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High levels of ground level Ozone, common during the hot summer months in Phoenix,  is a significant cause of respiratory symptoms, particularly for those who have allergies and asthma.

But do not feel left out.  Fall will be coming to the desert soon and along with it the seasonal bloom of grass and weed pollen.  And you won’t need a time machine to find it.

Brian Millhollon, MD

House Dust Mite

House Dust Mites and Monsoon Season in Phoenix

It is monsoon season in Phoenix and the weather is hot and sticky.   As uncomfortable as it may feel, the outdoor humidity level in Phoenix this time of year rarely exceeds 50% and the indoor humidity levels in the typical Phoenix home, with air conditioning running day and night, may average no more than 30-40%.   These levels are still fairly low when compared with the dripping misery the residents of Houston, Mobile, or Chicago have to endure every summer, but significantly higher than the desiccating 21% average humidity in our winter and spring.

Average Humidity In Phoenix 2016

Humidity levels In Phoenix, AZ  July 2016

Humidity levels Houston, Texas August, 2016

Humidity levels Houston, Tx  August, 2016

Why is this important for people with allergies? Many migrants to Phoenix from more humid lands do say that they feel better  living in the dry, desert climate but most important from an allergy perspective, low humidity means no dust mites.

The House Dust Mite is the poster child for indoor allergies in many parts of the world. downloadInnumerable numbers of these microscopic insects eat, grow, raise families, and poop in the part of the home were we spend most of our time, the bedroom.   They like our beds because it provides a rich source of their favorite food: people dander. House Dust Mites feed on the dead skin scales (dander) than we leave behind while tossing and turning trying to get our 8-10 hours.   After a zillion generations of living, eating, pooping, and dying in our beds, the accumulation of house dust mite related “material” in our mattresses, pillows, and comfy down comforters can be disgustingly rich. And all of this is allergenic.
sleeping girl

House dust mite allergy is a major cause of allergic rhinitis and asthma and significant recourses have been directed at limiting our exposure to dust mite allergens in the home, including pillow and mattress covers, removing stuffed animals from the bedroom, pulling up carpeting and rugs, removing upholstered furniture, taking out venetian blinds, and (Say it ain’t so!) removing ceiling fans, to name a few. However in spite of all these disruptive and potentially expensive undertakings in the fight to control the lowly mite,  the most effective deterrent by far has been to reduce indoor humidity.

Like most living things, House Dust Mites are mostly water and since they cannot go downstairs to get a drink of water when they get thirsty, they need to absorb moisture from the atmosphere. Many studies have shown that indoor humidity levels of around 75% are needed for dust mites to thrive.

Which brings me back to why humidity in Phoenix is an important allergy topic. I recently started monitoring the humidity level in my home with a hydrometer. This device keeps track of the current, low, and maximum humidity levels in the home year round.

 

2017-07-18 09.05.17This is a picture of the hydrometer’s current reading. The indoor humidity has stayed around 30-40% during our most humid time of year with a rare spike to just above 50% during a recent storm.   These humidity levels are too low to support House Dust Mite growth.

Unseen monsters, particularly those as ugly as the House Dust Mite, are frequently blamed for our problems when the real cause is unknown, but when we are experiencing mystery allergy symptoms in the home, unless there is an indoor source of moisture, such as an evaporative cooler  or a 500 gallon indoor aquarium or hot tub, a home may contain a lot of dust but not dust mites. Steroid Devil

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What Is In Allergy Shots?

A patient’s father recently asked me an insightful question about allergy immunotherapy. Allergy shots had been recommended for his son to treat his seasonal allergy and asthma symptoms and he wanted to know how we decided what allergens to include in the serum.

In some cases, as I explained, the answer is fairly straightforward. If his son had year round allergy symptoms that worsened when he was home on weekends, a very strong reaction to cat dander on allergy testing, and lived in a home with six cats, desensitizing to cat would definitely be a high priority.

More often, the decision is a little more involved but we start with the  following questions:
1. What is the patient sensitive to on allergy testing? When we read an allergy test, a positive reaction is defined as an increase in wheal size (raised area) of 3 mm or greater compared with a negative control or redness around the test site of 10 mm or greater. Skin test reactions are often much larger, however for an allergen to be considered clinically significant, it only has to reach the minimum size.

2. Is the patient currently exposed to the allergens that show positive on the allergy test?  The answer to this can be a bit tricky. For example, a number of people show positive reactions to House Dust Mite on allergy testing. And yet, most experts agree that House Dust Mite levels in the typical Arizona home are too low to cause significant symptoms. This is because House Dust Mites need an indoor humidity level of at least 50% for most of the year to thrive and the majority of homes in the Phoenix area rarely have indoor humidity levels this high. When there is a question, a simple test is to measure the indoor humidity levels in various rooms in the home with an inexpensive hydrometer. Unless the hydrometer readings are above 50%, we may not need to include Hose Dust Mite in the serum mix. However, if a patient frequently travels to more humid climates (anywhere but the South Western United States) and has increased symptoms on these trips, treatment for House Dust Mite may be recommended.

House Dust Mite

House Dust Mite

Why would you react to an allergen on an allergy test if you are not exposed to it?   There are several possible explanations. Your allergic sensitivities  may have developed when you were living in an area where the allergen is more prevalent. For example, if you lived in New Orleans for a number of yeas before moving to Arizona, you might have a strong sensitivity to House Dust Mite on an allergy test because of the high level of mite exposure on the Gulf Coast, but mites would be an unlikely cause of allergy problems in your new home in the desert. Cross reactivity is another reason that you may show a positive test to an allergen that you  have never been exposed to.   For example, the major allergenic protein in House Dust Mite is also found in a number of other insects and is also present in the muscles of  shellfish. If you are allergic to shellfish, you may show a positive reaction to House Dust Mite on testing, even though you have never lived in an area where dust mites are prevalent.

Cat and dog dander exposure is another issue. Several studies have shown that animal dander in school classrooms and work places may reach levels high enough to cause allergy symptoms in sensitized people, even if they do not have pets. It is also possible to bring enough dander home from school or work on your cloths for levels in your home to reach symptom-causing levels!

You can have pet dander without having a pet

You can have pet dander in your home without having a pet

3. Can the allergen be avoided or eliminated from the environment? If a patient has significant allergy problems caused by an indoor pet and that is the only thing they are allergic too, relocating the pet from the home might be the best solution.   This is certainly true in principle but relocating a family pet from the home is frequently not an option and so management with allergy injections may be the only long term solution.

4.  Is the allergen available for immunotherapy? If you developed allergy problems soon after bringing home a pet llama from your travels to Machu Picchu, appropriate material for desensitization may not be readily available.  Because of cost restraints, the companies that provide the material for making allergy immunotherapy extracts limit choices to items that are frequently used.  Even though Phoenix is the 5th largest city in the US, the percentage of people that are exposed to the unique allergens of the Sonoran Desert is small compared with other regions.  For this reason, some allergens that may be important for those living in our area may not be available. For example, Palo Verde, the state tree of Arizona, is not generally available for allergy immunotherapy. What goes into allergy shots 2

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Chickpea Allergy

In the past few years I have discovered two foods that I really enjoy but did not eat growing up.   One is hummus and the other is falafel. In fact, I learned how much I enjoy both foods eating at the Pita Jungle in Ahwatukee. Their falafel sandwich with pita bread and hummus on the side is wonderful!   If you asked me a few years ago what hummus and falafel was made of I would have ( I am ashamed to say) drawn a blank. You of course know that both are made from the chickpea.

Chickpea is one of the earliest known cultivated plants. It is packed with nutrients providing high quality protein, carbohydrates and fiber, and is used in traditional dishes around the world. Because it is high in protein and low in fat, it’s popularity as part of a healthy diet has been increasing in the US over the past 10 years.

I recently learned that chickpea has other traditional uses. In some areas of India, for example, infants are bathed in a lotion made from chickpea flour. In fact, I recently saw a 10 year old girl in our office with a history of severe rash and itching of the skin after she was bathed in chickpea flower lotion as an infant.   Her family has had her avoid anything containing chickpea since that time but was concerned about cross reactivity between the chickpea and other foods.

Chickpea is a legume and therefore closely related to other common legumes used as food such as peanut, soy bean, and green pea. Because of this allergenic cross reactivity, many patients who are allergic to one legume will have a positive allergy test (skin test or blood test) to other legumes although they may be able to eat those foods without any problems.   Usually, people who are truly allergic to a legume (have had symptoms when eating the food) will have a larger reaction on an allergy skin test or a higher value on an allergy blood test, but this is not a reliable way to distinguish who is truly allergic from those who have a positive test because of cross reactivity alone.

As an example, the child who had the severe allergic reaction to chickpea flour as an infant tested positive to green pea, soy, and peanut on her allergy tests although she has been eating these foods all her life without problems.  I explained that the child had an allergic sensitivity to many legumes but was only allergic to Chickpea.  This is not an easy concept to grasp.

On the other hand, someone who grew up in the US with a severe peanut allergy may want to be careful before trying unfamiliar dishes in parts of the world where legumes, such as the Chickpea, are used extensively.

 

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Don’t Let Your Babies Have Allergy Testing

This month, the National Institute of Allergy and Infectious Diseases published new guidelines for when peanut should be given to infants. The hope is that fewer children will develop peanut allergy as a result of these new recommendations

Screen Shot 2017-01-20 at 10.54.56 AM

The revision of its guidelines for the introduction of allergenic foods was prompted by the startling results of a study published in 2015 called the LEAP (Learning Early about Peanut Allergy) trial. In this study children between 4 and 11 months of age who were considered to be at high risk for developing allergy to peanut were divided into two groups. One group was given peanut to eat on a regular basis while the other group avoided peanut-containing food.   At 60 months of age both groups underwent a food challenge with peanut.

The peanut food challenge was positive in 13.7 % of the children that avoided peanut but only 1.9% in the group that ate peanuts regularly. In children that had a positive allergy skin test reaction to peanut before the study, the results were even more impressive. There was a 70% reduction in the prevalence of peanut allergy in the group given peanut compared with the peanut avoidance group.  In other words, children who were given peanut-containing foods to eat on a regular basis at a young age were significantly less likely to develop peanut allergy.

Here are the New Guidelines

  1. In children who have severe eczema, egg allergy (defined as a history of an allergic reaction to egg and a positive allergy skin prick or a positive oral egg food challenge result), or both, either a blood test or skin test for peanut should be performed. If the peanut allergy test is positive, the child should be referred to an allergy specialist for evaluation and possible oral food challenge with peanut.
  1. Children who have mild to moderate eczema (not severe) should have peanut-containing foods introduced at around 6 month of age
  1. In children who do not have eczema or history of food allergy, peanut should be introduced in an “age appropriate manner in accordance with family preferences and cultural practices”

Take Home Message

There is strong evidence that early introduction of allergenic foods such as peanut protects children from developing food allergy and delaying introduction of allergenic foods may increase the risk of severe food allergy.

Children who do not have severe eczema or a clear history of egg allergy SHOULD NOT have a blood test for food allergy.  The high rate of false positive results in these tests may delay the introduction of allergenic foods and can therefore cause the problem they are trying to prevent.

Children with a history of severe eczema or egg allergy (or any other food allergy) should be referred to an allergy specialist for further evaluation.

Brian Millhollon, MD

 

 

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Goodbye Pecos Road: Our Lungs Will Miss You

For many years, residents of the shinny new master-planned communities of Mountain Park Ranch, The Foothills, and Club West in Ahwatukee had only one way in or out of their neighborhood, giving it the distinction of being called (not so fondly) the largest cul-de-sac in America. To get to work you had your choice of using either Chandler Blvd or Ray Road, two giant arms of a horse shoe-shaped loop, both with a million cars stopped at a million red lights, all trying to get to the interstate at the same time every morning and back to home and supper at the same time every evening.   This tedious, wearisome daily exercise in commuter angst was the one thing that made many homeowners seriously question the wisdom of moving to Ahwatukee.

Then Pecos Road opened up: Ten miles of four-lane heaven connecting the outer frontier of Ahwatukee to Interstate 10 with only three lights.   Like most residents of The Foothills or Clubwest, Pecos Road was my daily commute. I was greeted with hopeful sunrises over the East Valley each morning and contemplative sunsets over the Estrella Mountains and Gila River Indian Reservation in the evening.

pecos sign3I took up cycling 5 years ago (mid-life crisis or early onset dementia?) and like most of the local lycra-ed community trying their best to out-pedal old age, Pecos Road became my second home; the place for serious training when long intervals were needed or to join friends for group rides and the occasional kamikaze sprint at the roads end. On Pecos you could spread you wings and fly for miles.

In less than a year from now, all that will change and Pecos Road will be no more, replaced by a freeway that will provide a bypass route for an endless line of trucks plodding West or East on Interstate 10.

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The passing of Pecos Road and the coming of the trucks was on my mind today when I read two articles in the Journal of Allergy, Asthma, and Immunology about the harmful effects of living close to a busy freeway.

The first: Inhalation of diesel exhaust and allergen alters human bronchial epithelium DNA methylation, presents evidence that exposure to diesel particles and common environmental allergens, such as pollen and mold, can alter the DNA of the lung.   This change can produce lasting effects on gene expression, cell function, and health. In other words, exposure to diesel particles can alter your DNA in such a way that you develop allergies or asthma, even if you, or your relatives, never had allergies before.

The number of people with allergies and asthma has increased significantly over the past several decades – a rise that has occurred almost exclusively in industrialized countries.   Since exposure to air pollution is one of the factors that characterizes life in the developed countries, the alteration of our DNA by diesel particles may be one of the mechanisms responsible for the world-wide asthma and allergy epidemic.

The second article, Traffic-related air pollution exposure is associated with allergic sensitization, asthma, and poor lung function in middle age, reports more bad news for communities planted close to major freeways.   Numerous studies have shown exposure to traffic-related air pollution to be associated with respiratory problems in children. This study, however, focused on the effect of air pollution on middle aged adults. The researchers concluded that even relatively low levels of air pollution during middle age is associated with increased risk of allergic sensitization, asthma, and diminished lung function.

The growing body of information documenting the harmful effects of traffic-related air pollution is certainly concerning to residents of any community located close to a major freeway. It doesn’t help that in Ahwatukee, these harmful health effects compound the growing sense of loss that many feel as they watch progress take away an old friend.

Brian Millhollon, MD

 

 

 

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Iodine and Seafood Allergy: Unconventional Wisdom

I recently evaluated a patient referred for seafood and iodine allergy. As a child she had an episode of vomiting and rash after eating shrimp although the details of the episode were vague since she was only three at the time.  She does recall being told that she was allergic to shellfish and should avoid all fish and shellfish, a recommendation she has followed for the past forty years.

When in her twenties, she had a head injury as a result of a skiing accident (she ran into a tree) and a CT of the head was ordered.   An injection of iodine-based contrast dye was  to be given before the x –ray so that blood vessels and possible bleeding could be seen more clearly. She mentioned her shellfish allergy to the technicians performing the test and so Benadryl and a steroid were ordered by the physician to prevent an allergic reaction to the iodine since it was well known that seafood contained a lot of iodine.

Worrying about an allergic reaction, she became quite anxious during the x-ray and developed a few hives, something that happened fairly often when she became nervous and upset. Since if was not clear what cased the hives, she was given more Benadryl and steroids and it was suggested that she warn her doctors that she was allergic to iodine based contrast materials as well as seafood.

About a month before coming into our allergy clinic, she had been in to see her family doctor for her yearly physical and a small nodule was noticed in her neck. She was sent for thyroid tests and a thyroid ultrasound, which confirmed a thyroid nodule, and so another scan using radioactive iodine was ordered.   She told her doctors that she could not have anything with iodine since she was very allergic to both iodine and seafood. This led to a prompt referral to an allergist.

As it turned out, allergy testing to fish and shellfish (crab, lobster, and shrimp) was  negative.   A food challenge to shellfish was offered and she was able to eat a small amount of crab cake under observation in the office without any problems.

This case is not unusual and highlights a common misunderstanding about seafood allergy and iodine.

Iodine Allergy is a Myth

Iodine allergy does not exist.   Iodine is an element that occurs naturally throughout nature and can be found in the periodic table along with other elements such as oxygen and iron. It is found to a varying degree in most of the food we eat every day. If we had allergies to these common elements we would be in serious trouble.iodin-2

Shellfish allergy occurs because of sensitivity to a muscle protein called tropomyscin which is found in all shellfish as well as in many insects. If you are allergic to one shellfish, such as shrimp, you are also at risk of reacting to other shellfish such as lobster, crab, and mollusks.

Allergy to fish is caused by sensitivity to a different protein unique to fish and not found in shellfish.   You can be allergic to shellfish and eat fish without difficulty and vice versa.   However, cross contamination, such as might occur in a seafood restaurant where shrimp is cooked in the same pan as the fish, can cause problems.

Not So Wise Conventional Wisdom

So where did the belief that being allergic to seafood put you at risk of being allergic to iodine come from? As it turns out, this is a very good example of a conventional wisdom. Conventional wisdom is a commonly held belief that is assumed to be true by laymen and professionals alike because it has always been assumed to be true and sounds like it should be true. Conventional wisdom can go unchallenged for many years, finding it’s way into text books and  being taught in university, before finally being put to rest by the truth.  Shellfish does contain more iodine than many other foods although this has nothing to do with shellfish allergy.

Both allergic and non-allergic reactions do occur to contrast materials containing iodine although these reactions are not caused by an allergy to iodine and are not related to seafood allergy.   People who have other allergies, such as to pollen, animal dander, or foods, may be at an increased risk of having an adverse reaction to an iodinated radio contrast material, but being allergic to seafood does not place you at any greater risk compared with other allergies.

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When is a Food Allergy Test NOT a Food Allergy Test?

Jason is now 15. He is taking AP calculus at Desert Vista High School, plays La Cross after school, is getting his driver’s permit next week, and plans to go to college and study electrical engineering after graduation. He is smart, tall for his age, and spends a little too much time playing video games.

He is also deathly afraid of peanuts.

He is afraid, in spite of the fact that he has never eaten a peanut. He has never enjoyed a Snickers bar, Reese’s Cup, or Kung Pao Chicken, and has certainly never eaten a peanut butter and jelly sandwich for lunch.

And yet, as long as he can remember, his parents have sternly warned him to stay away from peanuts.   He was not allowed to eat lunch with his friend’s at school because he had to eat at a special “peanut free” table and could not have snacks brought by other parents to baseball practice because they might be “contaminated” with peanut.

His parents have had to buy three sets of Epi Pens each year to keep at school, at home, and at his grandparents home, to be used in case he had a severe allergic reaction after eating peanut by mistake. This year his family spent more than a thousand dollars on the Epi Pens.

All in all, Jason’s life and the life of his family has been complicated by the serious threat of peanut allergy. And yet, Jason is not allergic to peanut.

The problem began when Jason was just turning two. He was spending the day at his grandparent’s house and developed a rash on his cheeks and vomited.   His parents became concerned that he may have had an allergic reaction to something he ate and so took him to his pediatrician who decided to run a food allergy panel just to be sure.

The test came back positive for peanut. The pediatrician suggested that it might be best for Jason to avoid peanuts since if was unclear if he may have eaten something that contained peanut at his grandparent’s house.   His parents read a story about a child with severe peanut allergy who died after being kissed by someone who had eaten a peanut and so requested an Epi Pen to keep on hand. All family members, friends, and teachers, were instructed on the importance of strict peanut avoidance when around Jason and on the use of an Epi Pen.

I saw Jason for first time six months ago.   His parents needed a refill of the Epic Pens and since his pediatrician was no longer practicing, they decided to make an appointment with an allergist.

After talking with Jason and his mother, it was clear that Jason did have allergies. He sneezed frequently, complained of stuffy nose and itchy eyes during the spring and fall, particularly while playing La Cross, and on occasion had wheezing and chest tightness after spending time around a friend’s cat.   Mom was not concerned about these symptoms, lot’s of people had them, but she with very concerned about his severe peanut allergy.

Because of his history, allergy testing to pollen, cat dander, and peanut was completed. The results showed very strong reactivity to grass, tree, and weed pollen as well as to cat dander. The skin test to peanut was also mildly positive.

How do we interpret these results? Most importantly, is Jason allergic to peanut?

To begin we rely on three sources of information to help us make a diagnosis of allergy: the patient’s history, laboratory tests, and a food challenge.

In Jason’s case, the history is not very strong for peanut allergy. In fact, it is not clear if he has ever been exposed to peanut.

What about the positive blood test and skin test for peanut allergy?

Both tests rely on the detection of a specific antibody produced by the body that reacts with peanut. When we find these antibodies, called IgE or immunoglobulin E, we can say that the patient shows sensitization to the food being tested. Both the blood test run when Jason was two and the recent skin test are technically not allergy tests, but tests for sensitization.

This distinction in terminology is important because many people have sensitization to a food (based on skin or blood tests) that they have eaten their entire lives without problems. Since food allergy by definition is adverse symptoms caused by exposure to a food that a patient is sensitized to, then without symptoms, there is no allergy.

If we define a perfect food allergy test as being reactive or positive in 100% of patients who have true allergy to the food and non-reactive or negative in 100% of patients who are tolerant of the food, meaning it is safe for them to eat it, then conventional food allergy testing is not very good. In fact, conventional food allergy testing has an approximately 50% false positive rate: Half of the patents that test positive to a food on these allergy tests are NOT allergic to the food. The test’s ability to rule out allergy is better, by some estimates more than 90%: There is less than a 10% chance that a patient with a negative test to a food will have an allergic reaction if they eat the food.

When we say that conventional allergy tests for peanut allergy have a 50% false positive rate we do not mean the test result is an error or mistake. The test accurately detects allergic or IgE antibodies to peanut. But as was mentioned, the presence of these antibodies does not always cause problems when the patient eats peanut and therefore is considered a falsely positive test for food allergy.

To understanding WHY we can have allergic antibodies to a food that we tolerate it is helpful to understand a few things about proteins. You can find a brief introduction to proteins here.

Peanuts, as well as most other foods, contain multiple proteins. The proteins in peanut are given numbered names beginning with Ara h (from the scientific name for peanut Arachis hypogaea). The peanut proteins Ara h1, Ara h2, Ara h3, Ara h6, Ara h8, and Ara h9 have been detected and allergic IgE antibodies have been found that react with each of these proteins.

Some of these peanut proteins, such as Ara h8, are very similar to proteins found in pollen produced by allergenic plants. In fact, if a patient is allergic to birch tree pollen, the anti-birch tree IgE antibodies they produce are likely to react with the Ara h8 protein in peanut. Patients with allergic antibodies to Ara h8 alone rarely have significant peanut allergy and yet will have a positive skin or blood test to peanut. One study showed that 79% of patients who had allergies to pollen reacted positively to peanut on an allergy test but were tolerant of peanut.

Other studies have shown that patients with high levels of allergic antibodies to the Ara h2 protein in peanut are more likely to have true peanut allergy. These observations have led to the development of component allergy tests were a patients blood can be tested for allergic antibodies to a specific food protein, not just the whole food.

Component testing for peanut allergy does show improved diagnostic accuracy compared with conventional blood tests, although it continues to have a high false positive rate and unfortunately can also be negative in patients who have true peanut allergy.

Component allergy testing for peanut was ordered for Jason and the results showed positive to Ara h8 only suggesting that the positive result on the skin test and earlier blood test occurred because of his strong sensitivity to pollen.

The results were discussed with Jason’s parents who asked if there was any other test that might be used to confirm that he is not allergic to peanut.

In fact, the most reliable and considered to be the gold standard for making a diagnosis of food allergy, is the double-blind, placebo-controlled food challenge. In this test, the patient is given a sample of the test food as well as a sample of a similar, non-allergic food as a placebo. Double blinded means that the doctor and technicians conducting the challenge as well as the patient, do not know which is the real test food and which is the placebo. The test is considered positive if the patient shows obvious signs of a reaction after eating the test food but not after eating the placebo.

There are a number of problems with the double-blind, placebo-controlled food challenge: It is difficult to perform, requiring significant time and recourses; A patient can have a severe allergic reaction to the food and therefore the study must conducted by trained personal in a setting that is capable of handling a severe emergency; and it is not always possible to find a suitable food to serve as a placebo.

Because a food challenge carries the very real risk of a severe allergic reaction it is rarely done if either the history or laboratory tests strongly suggest allergy. Open challenges to a food conducted in the allergist office is considered to be an alternative to a blinded, placebo-controlled challenger if the likelihood of significant allergy is considered to be very low based on history and previous tests.

Because of the weak history for peanut allergy and the results of component allergy testing, a peanut challenge in the office was offered to Jason and his parents.

When the food challenge was discussed with Jason he became very anxious and said that he did not see any reason to do it since he has done well staying away from peanut his whole life. He said he felt sick just thinking about it.

Hopefully, Jason’s fear of peanut allergy will subside with time and education and he will someday be able to enjoy a peanut butter and jelly sandwich or Snickers Bar.  And hopefully, improved testing methods as well as better understanding of food allergy will make such cases of unnecessary fear and anxiety over something to be enjoyed a thing of the past.

Brian Millhollon, MD

 

 

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Pet Dander Allergy

Allergy to a furry pet is a major risk factor for the development of asthma and is the one of the most common causes of allergy and asthma symptoms.  In fact for children, exposure to pet dander causes more asthma and allergy attacks than exposure to pollen. In Arizona, where the dry climate and use of central air conditioning most of the year eliminates the problem of house dust mites, allergy to a pet dog or cat is the number one cause of indoor allergy.
House dust mite

House Dust Mites are not a signifiant allergy problem in Arizona

Dander Everywhere
Dander is a microscopic, sticky substance that contains sloughed skin cells coated with dried oil and saliva.  It is very light, floats in the air, and sticks to everything: walls, ceilings, furniture and you.   An estimated 62% of americans have at least one household pet, and because dander is such sticky stuff, all this dander is carried around on pet owner’s clothes and belongings and are deposited everywhere they go. Studies have shown that significant levels of animal dander is found in schools, hospitals, day care centers, and other public places as well as in the homes of individuals who do not have pets.  The level of dander in public areas is high enough to cause significant asthma and rhinitis symptoms in anyone with a pet dander allergy.
Max

Max is far too cute to cause allergy problems

I’m Not Allergic to MY Dog
I have always found it interesting that pet owners frequently do not recognize that their pet is the cause of their allergy or asthma problems.  Some of this may be denial or wishful thinking, but it may also be related to the fact that pet dander is so consistently present with pet owners, both in and out of the home, that is difficulty to identify the pet as the source of the problem.  In my experience, many pet allergic patients will acknowledge problems when around a neighbor’s pet, but are quite certain that they are not allergic to their own.
It is not uncommon for children who grew up in a home with a pet to go away to college and on returning to their home for the holidays, discover that they are now allergic to the cat or dog. It is likely that they were always allergic to the pet but did not recognize it as long as they were in constant contact living at home.
 
A Few Additional Facts About Pet Allergy
  • Hypoallergenic dogs or cats are a myth.  In fact, studies have shown that hypoallergenic breeds of dog may produce significantly MORE allergenic dander than conventional breeds.mythological-1
  • Most owners of hypoallergenic breeds BELIEVE their pet causes fewer problems.
  • Pet dander particles are large enough to be removed by conventional central air conditioning filters. HEPA filters are not needed. Because most of the airborne dander sticks to surfaces or is removed by central air conditioning filters, a small air purifier is unlikely to offer significant additional benefit.
  • If you have carpeting in the home most of the dander will collect in the carpet and can be difficult to remove.
  • If you have hard surface flooring more dander will suspended in the air, particularly when sweeping.
  • Damp mopping floors and wiping walls is the best way to clean dander from a room.
  • Some people have more allergy symptoms when the carpet is wet, such as after shampooing.
  • It can take 6 months to a year for dander in a home to lose it’s potency.
  • Cat urine can be very allergenic; having a litter box indoors increases allergen exposure significantly.
  • The most effective way to treat pet dander allergy is to remove the pet from the home.  Because this is frequently difficult or impossible, desensitization to the dander by allergy immunotherapy can be the most effective long term solution.