It it a Cold, Sinus Infection, or Allergy?

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In Arizona, one of the challenges patients and physicians face during February and March is determining if that runny nose, scratchy throat, and sinus pain is the beginning of the spring allergy season, a late winter cold, or worse.  Here are a few clues to help sort it out.

  1. Allergy itches.  Most seasonal allergy attacks involve itching, either of the eyes, the nose, the throat, or skin.  When an allergic reaction occurs, histamine is released into the tissues causing redness, swelling, and itching.  Histamine is also released during a viral cold (which is why antihistamines are frequently prescribed for a cold) but this is not the primary chemical mediator causing symptoms.  If there is no itching, it probable isn’t allergy.
  2. Colds last about a week. Viral cold symptoms peak around day three, begin to level off by day five, and then begin to resolve.  You may not be well by the seventh day but you should be significantly better compared to how you felt on day three.  A sinus infection is usually a viral cold that becomes complicated by a bacterial infection.  It begins like a cold but rather than getting better by day seven, things are getting worse with increased discharge, pain, and possible fever.  You should see a doctor if cold symptoms persist or worsen beyond the seven day mark.  The allergy timeline is much less predictable with allergy symptoms coming and going throughout the season.
  3. Everyone else is sick.  If everyone in your cubicle, classroom, or home has the same deep cough or sore throat, it is likely a cold.  During a rough allergy season, a lot of people may be sneezing at the same time, but those affected do not cluster in a family, school,  or work-place the way a communicable virus does.
  4. Olive trees in winter.   If you know what you are allergic to (Olive trees, for example) and you know when they pollinate (Olive tree in April), it is unlikely that your February and early March symptoms are caused by allergies (if Olive is the only thing your allergic too).

Arizona Winter Allergy Misery Mystery

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Non-stop sneezing, horrible itchy eyes, wheezing and coughing,  all during the one time of year when allergies are supposed to be hibernating!  The bermuda grass is still dormant, the weeds are frozen from the recent frost, and the citrus and Olive trees will not start budding for several months.   What could possible be causing all this allergy misery in the middle of winter?

The answer is Juniper and Cedar pollen. Although a few ornamental varieties of these evergreen trees are found in yards around the valley, they are not as numerous as Mesquite, Palo Verde, Palm, or Acacia trees.   However,  at higher elevation, varieties of Juniper such as Oneseed Juniper (Juniperus monosperma) or  Alligator Juniper  (Juniperus deppeana) cover thousands of acres in every direction surrounding Phoenix.    When conditions are right, a cloud of Juniper pollen is carried by the winds down into valley where it becomes part of the brown haze hanging over the city.

So if you are sneezing and itching in January and February in Phoenix, and are wondering what’s going on, look to the hills.

Alligator Juniper

Alligator Juniper Payson, Arizona

What is Sulfite Allergy?

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Sulfites are a group of similar chemicals that are commonly used as a food enhancer and preservative to maintain food color and prolong shelf-life, prevent the growth of micro-organisms, and to maintain the potency of certain medications. They may come in various forms, such as:

  • Sulfur dioxide
  • Potassium bisulfite or potassium metabisulfite
  • Sodium bisulfite, sodium metabisulfite or sodium sulfite

The use of sulfites as preservatives in foods and beverages increased dramatically in the 1970’s and 1980’s. After several cases of severe reactions to sulfites were reports, a ban by the FDA went into effect in August, 1986. This ban prohibited use of sulfites in fresh fruits and vegetables. Although reactions to sulfites were recognized initially with salad bars in restaurants, this is no longer a common source for sulfite exposure. Sulfites continue to be used in potatoes, shrimp, and beer/wine, and are also used in the pharmaceutical industry. Although shrimp are sometimes treated with sulfites on fishing vessels, the chemical may not appear on the label. A list of foods associated with sulfites can be found below.

Sulfites occur naturally in all wines to some extent and are commonly introduced to arrest fermentation at a desired time, and may also be added to wine as preservatives to prevent spoilage and oxidation at several stages of the winemaking.  In general, sweet (dessert) wines contain more sulfites than dry wines, and white wines contain more sulfites than red wines.  In the United States, wines bottled after mid-1987 must have a label stating that they contain sulfites if they contain more than 10 parts per million.

Labeling regulations don’t require that products indicate the presence of sulfites in foods other than wine; however, many companies voluntarily label sulfite-containing foods. Regulations do exist that require that ingredients lists show sulfites if they were added to a product, but this requirement applies only if they were intentionally added in formulation and not if they are contained in an ingredient. If a product includes an ingredient that contains sulfites, such as dried fruit, then the ingredients label will list only “dried fruit” and is not required to indicate whether the dried fruit itself contains sulfites. Furthermore, the products most likely to contain less than 10 ppm (fruits and alcoholic beverages) do not require ingredients labels, so the presence of sulfites is usually undisclosed.

Most beers no longer contain sulfites. Sulfites are added to many medications, including some of the medications given to treat asthma and allergic reactions.

Although a reaction to sulfite is not a true allergy, individuals who are sensitive to it may experience a variety of symptoms including asthma, diarrhea, abdominal pain and cramping, nausea and vomiting, hives, itching, localized swelling, difficulty in swallowing, faintness, headache, chest pain, loss of consciousness, “change in body temperature,” “change in heart rate,” and non-specific rashes.  For normal individuals, exposure to sulfite appears to pose little risk. Sulfite-sensitive asthmatics, however, are at risk of having  a severe asthma attack when exposed to sulfites.

To date there is no specific diagnostic test, other than a food challenge, available to determine if someone has a true sulfite sensitivity.   A double-blinded, placebo-controlled, food challenge in which neither the doctor of the patient knows knows whether a food containing sulfites or a placebo is given while symptoms are monitored is required to confirm a case of suspected sulfite sensitivity.

Foods Frequently Containing Sulfites

  1. Alcoholic/non-alcoholic beer, cider, wine
  2. Baked goods, e.g., breads, cookies, pastries, waffles
  3. Bottled lemon and lime juice/concentrate
  4. Canned/frozen fruits and vegetables, e.g., mushrooms, sliced apples, olives, peas, peppers, pickles, pickled onions, tomatoes
  5. Cereal, cornmeal, cornstarch, crackers, muesli
  6. Condiments, e.g., coleslaw, horseradish, ketchup, mustard, pickles, relish, sauerkraut
  7. Deli meat, hot dogs, sausages
  8. Dressings, gravies, guacamole, sauces, soups, soup mixes
  9. Dried fruits/vegetables, e.g., apples, apricots, coconut, mincemeat, papaya, peaches, pears, pineapple, raisins, sun dried tomatoes
  10. Dried herbs, spices, tea
  11. Fish, including crustaceans and shellfish, e.g., shrimp (fresh/frozen)
  12. Fresh grapes, lettuce
  13. Fruit filling, fruit syrup, gelatin, jams, jellies, marmalade, molasses, pectin
  14. Fruit/vegetable juices, e.g., coconut, grape, sparkling grape, white grape
  15. Glazed/glacéed fruits, e.g., apples, grapes, maraschino cherries
  16. Potatoes, e.g., frozen french fries, dehydrated, mashed, peeled, pre-cut
  17. Snack foods, e.g., candy, chocolate/fruit bars, tortilla/potato chips, soft drinks, trail mix
  18. Soy products
  19. Starches, e.g., corn, potato, sugar beet; noodles, rice mixes
  20. Sugar syrups, e.g., glucose, glucose solids, syrup dextrose
  21. Tomato paste/pulp/puree
  22. Vinegar, wine vinegar

Decoding Gluten Sensitivity

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“Gluten free” is the new food-fad buzz word with gluten free labels appearing everywhere from salmon to beer.   By some estimates, over a quarter of americans are limiting their intake of gluten.   Entrepreneurial as well as main-line food producers have jumped on the band wagon with both feet, and  have turned “Gluten free” into a $2 billion industry.

And yet, in spite of the explosion in gluten free diets, diet books, and diet products, less than 1% of americans have any real reason to avoid foods containing gluten.  That very real reason is a condition called Celiac disease.  Celiac disease is not a true food allergy but rather a type of  autoimmune disease.   Gluten is a protein found in common grains such as wheat, rhy, and barley.  When this protein in digested in the small intestines, it links up with a chemical in the tissue lining called tissue tranglutaminase.  For unknown reasons the immune system of patients with Celiac disease identifies the linked-up gluten/tissue transglutaminase complex as a threat and produces antibodies to attack it.  This attack of the immune system causes inflammation in the lining of the small intestines resulting in malabsorption as the body’s ability to absorb nutrients, minerals and fat-soluble vitamins is impaired.   If untreated, this can lead to weight loss, diarrhea, and fatigue.  The condition can be reliable diagnosed using a blood test and confirmed by a biopsy of the small intestine.   Treatment is effective but difficult and involves life long, strict avoidance of food containing even trace amounts of gluten. In some patients with Celiac disease, even oats have to be eliminated.

Gluten is not inherently dangerous and is only a problem in those few individuals whose immune system misbehaves by producing anti-gluten antibodies.

A very different condition is wheat allergy.  This is a true food allergy and can result in immediate symptoms after food containing wheat is eaten.   Significant allergy to wheat is also uncommon, affecting less than 1.5% of children, and can be easily diagnosed with an allergy skin test or blood test.

So if celiac disease and wheat allergy are rare conditions, the two conditions combined affecting less than 3% of the population, how did “gluten free” become a $2 billion industry.

Like a lot of diet and health fads that have come and gone, there seems to be a common formula.

  • Start with a kernel of well established truth:

“Gluten causes inflammation” (but only in patients with celiac disease).   “Inflammation is bad and is associated with a number of chronic health conditions that are poorly understood and have no known cure like arthritis, asthma, irritable bowl syndrome, chronic pain, migraine headaches, and fatigue”.

  • Extrapolate from the facts while ignoring a few key points:

“Since gluten can cause inflammation (ignore the fact that this is true in less than 1% of people) and inflammation is the cause of many frustrating medical conditions,  eliminating gluten from your diet may provide relief for those suffering from  headaches, fatigue, chronic pain, irritable bowl syndrome, and headaches by reducing inflammation in your body”.

  • Rely on anecdotal evidence and personal testimonies as confirmation of your hypothesis:

As one web site selling gluten-free products explained:  “You can be sensitive to gluten even though tests for celiac disease and wheat allergy are negative but the only way to know is to go on a strict gluten free diet and see if you feel better”.  However,  following a strict gluten free diet is very hard and many people mess up and so it you don’t feel better, this does not necessarily mean you don’t have a gluten problem, only that you weren’t careful enough”.   In addition, an estimated 40-50% of dietary calories in the american diet comes from carbohydrates, and a large portion of  these carbohydrates come from wheat products.  Because many  junk foods comes from wheat, avoiding wheat can not only result in a significant reduction in daily caloric intake but also in a switch to a healthier, more nutritionally balanced diet with less trans-fat.   And so in the end, patients who report “feeling better” after embarking on a gluten free diet may only be confirming that loosing weight and eating healthier foods can have a positive affect on ones health, and not that they are gluten sensitive.

You may find this recent in Natural Products Marketplace helpful.  http://www.naturalproductsmarketplace.com/articles/2011/01/gluten-free-just-a-fad.aspx

Egg allergy no longer a reason to avoid getting a flu vaccine

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Egg allergy no longer a reason to avoid getting a flu vaccine

From AAAAI:

According to a new paper  published on the American Academy of Allergy, Asthma & Immunology (AAAAI) website, recent studies show that most egg allergic individuals can receive the flu vaccine safely under the care of their allergist/immunologist.

“In the past, persons with egg allergy were told not to get the influenza vaccine because the vaccine contained egg protein and could trigger an allergic reaction. Research in the past year now shows that influenza vaccines contain only tiny amounts of egg protein. Clinical studies proved that the vast majority of persons with egg allergy did not experience a reaction when immunized with the influenza vaccine,” said co-author of the paper James T. Li, MD, PhD, FAAAAI.

Based on the examined research, the authors no longer recommend the practice of skin testing to the seasonal Trivalent Influenza Vaccine (TIV), although it may be useful as an extra level of caution in cases where the patient has a documented history of a past allergic reaction to the vaccine.

Anyone with a history of suspected egg allergy should first be evaluated by an allergist/immunologist for appropriate testing and diagnosis. Patients with a confirmed egg allergy can then receive the vaccine safely using one of two protocols: as a 2-step graded challenge or as a single, age-appropriate dose.

“It is not necessary to withhold influenza vaccination from egg allergic patients. Our recommendations provide two flexible approaches to vaccination. Each approach is backed with recent evidence that it is safe,” according to co-author Matthew J. Greenhawt, MD, MBA. “Most allergists should be able to identify with one of our recommended approaches, and as such should be able to vaccinate their egg allergic patients with confidence.”

The authors do note that the safety of these vaccines in individuals with severe egg allergy needs to be studied further.

Food-allergy fears drive overly restrictive diets

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This is a recent article from National Jewish Hospital in Denver:

Many children, especially those with eczema, are unnecessarily avoiding foods based on incomplete information about potential food-allergies, according to researchers at National Jewish Health. The food avoidance poses a nutritional risk for these children, and is often based primarily on data from blood tests known as serum immunoassays.

Many factors, including patient and family history, physical examination, and blood and skin tests, should be used when evaluating potential food allergies. The oral food challenge, in which patients consume the suspected allergenic food, is the gold standard test.

The researchers conducted a retrospective chart review of 125 children evaluated at National Jewish Health for suspected food allergies. Depending on the reason for food avoidance, 84 percent to 93 percent of foods being avoided were restored to their diets after an oral food challenge. The researchers published their study online in The Journal of Pediatrics on Oct. 29. It will appear in a later print version of the journal. “People with known food allergies, especially those with a history of anaphylactic reactions, should by all means avoid those foods,” said David Fleischer, MD, lead author of the study and Assistant Professor of Pediatrics at National Jewish Health. “However, a growing number of patients referred to our practice are being placed on strict, unproven food-elimination diets that have led to poor weight gain and malnutrition. These overly restrictive diets have been chosen for a variety of reasons, but overreliance on immunoassay tests appears to be the most common cause.”

Immunoassays detect antibodies in the blood to specific foods, which can potentially cause allergic reactions. Interpretation of the results, however, can be tricky. The tests’ ability to predict true food allergy has been validated for only five foods – cow’s milk, hen egg, fish, peanut and tree nuts.

For all other foods, the numbers derived from lab testing are suggestive but not definitive. Low test values suggest that a child’s immune system is sensitized to the food, but not necessarily to the extent that it will cause an allergic reaction. Higher values suggest an increasingly likelihood of true food allergy. None of the tests are 100 percent accurate, however, in predicting clinical food allergy on their own.

National Jewish Health physicians use blood tests as one piece of evidence in their comprehensive evaluation of food allergy. They also carefully evaluate a patient’s history, including any previous reactions to food, the type of reaction, the patient’s age, and the result of skin testing for food allergy. They generally perform an oral food challenge when the evidence is mixed and they want a definitive answer to the food allergy question.

Children in the study were avoiding 177 different foods based primarily on previous blood test results. In many cases, especially those with high test results for egg, milk, shellfish, peanut and tree nut, National Jewish Health elected not to perform oral food challenges. They did perform oral food challenges for 71 foods or about 40 percent of the cases where the clinical allergy was equivocal and it was important to determine whether or not the patient had food allergy. In 86 percent of those cases, the child passed the food challenge and the food was restored to the child’s diet. Overall, 66 of the 177 foods avoided because of blood tests were restored to children’s diets. For the entire study, 325 foods were restored to the diets of 125 children.

“When you are able to restore foods such as dairy products, egg, peanut, wheat, and vegetables to a child’s diet, it improves their nutrition, reduces the need for expensive substitute foods and makes meal time easier for families,” said Donald Leung, MD, PhD, senior author and Edelstein Chair of Pediatric Allergy and Clinical Immunology at National Jewish Health.

The problem can be especially acute among patients with eczema, also known as atopic dermatitis. Research suggests that specific foods can cause flare-ups in about one third of eczema patients. They commonly have high immunoassay tests to a variety of foods, many of which are not truly allergenic. As a result, many mistakenly avoid foods they believe are causing flare-ups, but neglect basic skin care that is vital to improving the eczema. One hundred and twenty of the 125 children in the study had eczema.

Early Introduction to Egg is Best

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Parents worried about childhood food allergies, and who delay the introduction of troublesome foods, could be unwittingly raising their child’s risk.

A Melbourne-based study has found infants who were not introduced to eggs until after their first birthday were up to five times more likely to go on to develop an egg allergy.

This was compared to those who ate their first eggs from age four to six months and, University of Melbourne PhD scholar Jennifer Koplin said, it added more weight to the recent shift in official advice.

“Until recently, Australian and international guidelines recommended that infants with a family history of allergy delay introducing allergenic foods such as egg, peanut and nuts until up to two to three years of age,” Ms Koplin said on Monday.

“Our study suggests that babies who ingest these foods at an earlier age may be less likely to develop food allergies as they grow older.

“It seems that early introduction of egg may protect against egg allergy, while delaying its introduction may put the child at increased risk of developing an allergy.”

The study, published on Monday by the Journal of Allergy and Clinical Immunology, took in 2,500 infants and the timing of their introduction to eggs was checked against those who later developed the allergy.

An early introduction to cooked egg – boiled or scrambled eggs for example – was found to confer more of a protective effect than first consuming eggs in baked form – in cakes or biscuits.

Of babies aged four to six months who were introduced to cooked egg, just 5.6 per cent developed an egg allergy compared with 27.6 per cent of those introduced to cooked egg after 12 months.

A family history of egg allergy did not appear be a factor in those children who went on to develop it, while duration of breastfeeding and introduction to first solids were also ruled out.

Associate Professor Katie Allen, from the Murdoch Childrens Research Institute, said more work was needed to check whether the same was true for other common allergenic foods such as nuts.

“Confirmation that early introduction is protective for other allergenic foods may help better inform parents in the future, and could have the potential to reverse the epidemic of childhood food allergy,” Dr Allen said.

The research forms part of a wider study led by Professor Allen at the Murdoch Childrens Research Institute to track food allergy prevalence and causes among Victorian infants.


Danny Rose, Medical Writer

October 4, 2010

AAP

What Are Hives?

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Hives is the common term for urticaria, a unique type of skin rash characterized by itchy, raised, welts, which may be few and isolated or large and numerous, covering large areas of the body.   Welts frequently form at sites of scratching or pressure such as around the waist or bra strap. Individual welts last only a few hours and then fade, only to be replaced by new lesions.   Other itchy rashes are frequently mistaken for hives.   If individual bumps last more than 24 hours then the rash is not typical hives.

We know what causes hives but we do not always know why.   Hives are the result of chemicals such as histamine released from a white blood cell in the skin cell called the mast cell.  Everyone has histamine-filled mast cells in the skin but as long as the histamine stays in the cell, it does not cause problems.  When the histamine is released, which occurs commonly in an allergic reaction, the result is redness, itching and swelling.   An allergic reaction to pollen typically causes itching, swelling and dripping of the nose as histamine is released in the nasal tissue from mast cells coming into contact with the pollen.   A reaction in the airways may cause an asthma attack.  In food allergy, the allergen, usually a protein, is absorbed into the blood stream and is distributed around the body.  Mast cells in the skin react to the food protein and release histamine.  Histamine released in the upper layers of skin cause hives while histamine released in the deeper layers may cause itching and swelling without obvious rash, a condition called angioedema.    A severe allergic reaction will cause sudden, widespread release of histamine .  Such a dramatic  release of histamine into the tissues of the body may result in a rapid drop in blood pressure as well swelling of the tissues around the throat and airways compromising breathing.  This rare but serious allergic reaction is called anaphylaxis.

Allergy is common and most true allergic reactions involve release of histamine from mast cells and, while allergic reactions to foods, insect stings, medications, contactants, and on occasion airborne allergen, frequently cause brief outbreaks of urticarial rash, hives that last more than 4-6 weeks are rarely caused by simple allergy.    In fact, in more than 90% of cases of hives lasting more than 6 weeks, an allergic cause for the rash cannot be found.   In these cases, the diagnosis is Chronic Idiopathic Urticaria.

Because the rash, itching an swelling of hives is for the most part caused by histamine, antihistamines are the primary treatment. Corticosteroids are often used for a short time get a bad case of hives under control although the side effects associated with long term use of oral steroids makes there daily use unworkable.   The dose of antihistamines required to treat chronic urticaria can be more the four times the dose commonly used to treat nasal allergies.

Hives are uncomfortable, at times scary, and almost always frustrating.  The desperate search to understand and eliminate the cause for the horrible rash and itching is usually unfruitful.  However, with proper treatment, it is manageable and usually (but not always) resolves in time.

September Asthma Epidemic

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With the new school year up-and-running, parents of children with asthma will be bracing for the yearly “asthma epidemic”.
Around the country, asthma attacks spike in late summer and early fall when children return to school from summer vacation.  This annual asthma flare-up accounts for a significant increase in emergency room visits, hospital admissions, and unscheduled trips to the doctor.
In Ahwatukee and other communities in Arizona, the spike in asthma symptoms may occur later in the fall  when night-time and day-time temperatures turn cooler, encouraging grass and weed pollination.  Bermuda grass pollen peaks in late summer and fall, just when children are returning to .   School playgrounds and sport fields are typically planted in Common Bermuda grass.  Russian Thistle, Careless Weed, and Ragweed pollen production also peaks in September and October.     Some children also react to pet dander either from direct contact with a classroom pet such as a rabbit or guinea pig, or on the cloths of children who have pets at home.
Although allergen exposure is an important trigger for many children with asthma,  the  most important  cause of asthma flares in children returning to the classroom from summer vacation is exposure to cold and flu viruses.  Although allergy is the primary cause of asthma, viral upper respiratory infections are the primary cause of asthma attacks.
So what can a parent of a child with asthma do to prepare for the fall asthma epidemic?   Although it is often possible for children to back off on their daily asthma controller medications during the months of summer vacation, these medications should be resumed when the children return to the classroom.  It may be too late to start the medication at the first sign of an asthma attack.  Every child with more than very mild, occasional asthma symptoms should have a personal asthma action plan constructed by their physician.  The asthma action plan may be based on symptoms or peak flow meter values or on a combination of the two and should give clear instructions on what actions to take if a child is having increased asthma symptoms.   A copy of the asthma action plan should be given to the school health office along with the child’s asthma rescue medication.  (Example asthma action plan)

Is Arizona Honey Good for Arizona Allergies?

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Many people believe that eating local honey will help with their seasonal allergy symptoms.  This belief is based on a half truth and one major misunderstanding.   The principle of desensitization, that exposure to small amounts of the thing you are allergic to will make you less sensitive over time is sound.   In fact, this is the principle behind allergy immunotherapy or allergy shots.  However, there is just not enough pollen in honey to have a lasting effect.  More importantly  however, is the fact that the pollen in honey comes from the wrong plants.   The plants that cause most seasonal allergy symptoms, grasses, weeds, and trees. are wind pollinated, not insect pollinated.  So bees do not visit these plants and so the pollen that causes allergies is unlikely to find it’s way into honey.