“My Worst Allergy Spring Was the Winter I Just Spent in Arizona”

When we think of allergy season, fall and spring comes to mind, but not so much winter.  Yet this December, January, and now into February, patients have been coming into our allergy clinic in the suburbs of Phoenix complaining of some of the worst allergy symptoms all year.  Typical complaints include sneezing, itchy nose, and particularly, very itchy eyes.

Alligator Juniper

Alligator Juniper Payson, Arizona

When patients undergo testing for allergies, many show sensitivity to a number of different allergens such as plant pollen, mold, foods, and animal dander.  However, in the case of the winter allergy sufferers, the majority show sensitivity to only one thing: juniper, or more specifically, Cupressaceae.

The Cupressaceae are a family of evergreen conifers found throughout the world. Arizona is home to a number of native species of cupressaceae including Rocky Mountain Juniper (Juniperus scopulorum), Utah Juniper (Juniperus osteosperma), One Seed Juniper (Juniperus monosperma), Alligator Juniper (Juniperus deppeana) and Arizona Cypress (Cupressus arizonica).

Although Phoenix has a number of ornamental varieties of Cupressaceae used in landscaping, the majority are found at 3000-7000 feet elevation and cover millions of acres surrounding Phoenix on all sides.    When conditions are right, a large amount of cupressaceae pollen finds its way into the valley.  One of the chief offenders is Arizona Cypress which is very prevalent in the higher areas surrounding the valley and produces  pollen November through March.

The pollen produced by the different varieties of Cupressaceae cross react with one another, which means that if you are allergic to one you will be allergic to all.  Mountain cedar (Juniperus ashei) is the leading cause of respiratory allergy in South Texas and affects so many with severe allergy symptoms that it has been given it’s own diagnosis, “cedar fever” .

Is it Allergy or a Cold?

It’s winter and  the season for runny, stuffy noses, coughing and hacking, and scratchy, sore throats – but not necessarily from allergies.  A question that comes up a lot this time of year is  how to tell the difference between allergies, a sinus infection, and a cold? This is, of course a trick question because a cold IS a sinus infection, technically speaking.  Most cold viruses not only affect the nose and throat but also the sinuses.  What about telling the difference between an allergy attack and an infection?  This can be a challenge at times but there are clues. Typically, allergies cause more itching and rarely pain and mucous is usually clear.  With an upper respiratory infection, drainage can be discolored, the throat can be raw and sore, and you may have a fever.   Also, allergies are not contagious and the fact that 70% of your school or office is home sick with the very same awful symptoms you just came down with might suggest a bug rather than a pollen problem.

This time of year, the primary allergen in the air is pollen from evergreen trees such as Juniper.   So knowing what you are allergic can help us interpret your symptoms.  For example if you are not allergic to Juniper, then respiratory symptoms during the winter are not likely to be allergy related, unless of course your aunt came to visit for christmas and brought her six cats.

You might ask: If it is not an allergy but an infection, then an antibiotic is needed to get better right? Antibiotics are one of the most important discoveries of our modern era.  They have saved millions of lives and turned the nightmare of a devastating infection in a child to a routine affair easily treated by a prescription from the family doctor.  But as miraculous as antibiotics are, they are worthless in the treatment of viral infections, and viral infections are the most common cause of respiratory infection in children and adults.

This however, has not stopped antibiotics from being routinely prescribed for cold viruses.  But how do we know if it is a cold virus and not a bacterial infection and one that would respond to an antibiotic and make me feel better in hours rather than days?  For the most part, a cold causes a lot of uncomfortable symptoms for the first 2-3 days, symptoms plateau around day 4-5, and then slowly improve, usually resolving completely by day 7-10. A cold may lead to a bacterial sinus infection but this rarely occurs in the first week of symptoms. Therefore, the major consensus guidelines for doctors suggest that antibiotics are rarely helpful and not recommended for most patients with typical cases of upper respiratory infection lasting less than 4 weeks.

So how successful are prescribers at following these guidelines? A recent study reported in The Journal of Allergy & Clinical Immunology (JACI),  reviewed the overall national use of antibiotics for adults with sinus infections.  Study data were taken from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 2006-2010, from the U.S. Department of Health and Human Services, and included antibiotic prescriptions associated with outpatient visits made by adults diagnosed with acute or chronic sinusitis. Over the five year study period, sinus infections  accounted for 11% of all primary diagnoses for ambulatory care visits  for which  antibiotics were  prescribed, more than any other diagnosis.  There were 21.4 million estimated visits associated with a primary diagnosis of acute sinus infection, and 47.9 million estimated visits associated with a primary diagnosis of chronic sinus infection.

Antibiotics were prescribed in 86% of acute sinusitis cases, in spite of established clinical practice guidelines recommending against the use of antibiotics for typical acute sinus infections.

No one wants to be sick and when we are ill with a cold we want to get better as soon as possible.  And although the approach: ”better to be safe than sorry and take an antibiotic at the first sign of symptoms rather than wait several weeks to see if it will get better on it’s own” may seem reasonable,  the potential consequences associated with excessive and unjustified use of antibiotics, including allergic reactions, severe adverse side effects, unnecessary costs, and increasing bacterial resistance, cannot be justified.

Both physicians, who want to help and may be afraid to say no, and patients, who may have unrealistic expectations, are to blame for the growing problem of inappropriate antibiotic use.   However, while most of us have grown up in the age of wonder drugs, we are now at risk of entering a new and very scary time called “the post antibiotic era”.    A place were no pill or shot will save us from foes that we have long thought vanquished.

So if you have a cold:  get plenty of rest, avoid public places when possible so that you don’t infect others, and give it time.  If you do not see any improvement in a week or so or if symptoms are getting significantly worse, see your doctor.

A Not-So-Nice Easter Rabbit

Rabbit Bush (Ambrosia deltoidia), flowering

It’s an unusual name for a weed: Rabbit Bush.  And although it is not clear where the name for this Arizona native variety of ragweed comes from, one thing is clear:  there is a lot of it and it’s a major cause of allergy problems in the spring.  In fact, Rabbit Bush is one of the most prevalent spring allergenic weeds in South Mountain Park and is therefore a significant source of ragweed pollen for Ahwatukee and surrounding areas.   Rabbit Bush (technically Ambrosia (Franseria) deltoidea and also known as triangle bur ragweed or tirangleleaf bursage) comes to life in the spring, particularly if we have had winter rain, producing copious amounts of pollen in the Arizona Sonoran desert from March until  May.   Allergenically,  it is closely related to other varieties of ragweed found throughout the Unities States and will trigger allergy symptoms in patients who have had problems with ragweed before moving to Phoenix.   Other native varieties of ragweed found in the Sonoran Desert include Canyon Ragweed, fond of desert washes, and Desert Ragweed, a smaller but also prevalent ragweed  in the Phoenix area.

Rabbit Bush (Triangular Bursage)

Fall Comes to the Desert

It’s finally starting to feel like fall.  Nighttime and early morning temperatures have dropped below 90 degrees, the monsoon humidity and risk of monster dust storms is on the decline, kids are back in school, and club sports are in full swing.   We are also seeing early signs of the Arizona fall allergy season.   Unlike the Midwest and the South, where fall can bring some of the worst allergy misery of the year, the fall allergy season in the desert can be hit or miss depending on the amount of monsoon rain during the summer.   This year, things are shaping up to be a real hit.  Higher than normal rain fall has produced a bumper crop of allergenic weeds including Russian Thistle (tumble weed), Careless Weed, and Ragweed.  In many parts of the country, ragweed pollen defines the fall allergy season.  In the Phoenix area, ragweed often plays a minor role in the fall allergy season because it is too hot and dry.  On the other hand, ragweed is a major cause of springtime allergy symptoms, particularly when the valley gets sufficient winter rain. This year may be an exception, and residents of Phoenix who usually have allergy problems during the spring may find themselves suffering as much itching, sneezing, and wheezing this September and October as they usually do in March and April.

Bermuda grass, although pollinating throughout the summer, becomes a more serious allergy problem in the fall as children start practicing and playing on bermuda grass sport fields.  Landscapers and homeowners also begin “scalping” and dethatching there bermuda grass lawns in preparation for planting winter rye grass. Scalping a lawn (mowing the grass very close to ground) sends a cloud of bermuda grass dust high into the dry fall air where it can be carried throughout the neighborhood.

All this increase in atmospheric pollen and particulate production is compounded by the phenomenon of temperature inversion.  In the fall, as the nighttime temperatures begin to drop, a layer of cooler air becomes trapped by a layer of warmer air above. Particulates, including dust and pollen, become trapped in this cool air mass close to the ground,  right at nose and mouth level.

Patients with asthma often have a harder time keeping under control during the fall.  This is not only the result of increased fall pollen and air pollution exposure but also because of the fall cold and flu season.  Viral upper respiratory infections are the number one cause of asthma attacks, particularly in school age children.

Arizona Cough

Cough is one of the most common symptoms prompting patients to see a doctor in the United States with an estimated 30 million trips to the doctor for this problem each year. More than 40% of the patients seen in our allergy and pulmonary practice between November and February complain of cough.

Cough is classified as acute, sub acute or chronic depending on how long the symptom has been present.   Acute cough lasts for less than three weeks and is most commonly the result of an acute respiratory tract infection. Other more serious causes of acute cough include pneumonia and in our clinic in Arizona, coccidiomycosis infection or valley fever.

A cough associated with typical cold symptoms may be called bronchitis, particularly when symptoms last for more than a week. Acute bronchitis is most often caused by a viral infection although other respiratory infections besides viruses, including Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Bordetella pertussis may be involved.  Although most viral infections cause symptoms lasting less than 2-3 weeks, some patients with viral or other upper respiratory tract infections will continue to cough for more than eight weeks after the acute infection.  This persistent cough may be the result of a type of airway injury.  Although the source of the infection is gone, the injury remains and takes time to heal.

Another important cause of acute cough in children in adults is pertussis (whooping cough).  Pertussis is a very contagious disease caused by the bacteria Bordetella pertussis. Before the advent of vaccinations in the 1940s, pertussis was a major cause of severe illness and death among infants and children.  Although cases of pertussis decreased by more than 99% after the introduction of pertussis vaccine, it remains a cause for concern, in part because of the incomplete protection provided by the vaccine and the increasing numbers of children that are never vaccinated.  In fact, pertussis is the only vaccine-preventable disease that is associated with increasing deaths in the United States.  In 2010, more than nine thousand cases of whooping cough were reported in California. At least ten infants died from the infection prompting the health authorities to declare a pertusis epidemic.

Pertusis infection usually begins with symptoms similar to the common cold although after several weeks, frequent and often violent coughing begins. The illness is most severe in infants and young children, particularly in those that have not been immunized. In adults, the only symptoms may be a persistent cough.

In a recent study published in The Journal of Allergy and Clinical Immunology (JACI), the risk of adults and children with asthma developing whooping cough was 1.7 times higher than those without asthma, suggesting that asthma significantly increased risk for whooping cough.

A cough lasting more than 4-6 weeks without a clear history of acute respiratory infection is considered chronic and is most likely the result of one of three conditions: asthma, rhinitis/sinusitis and gastroesophageal reflux disease.

Asthma and rhinitis/sinusitis are frequently the result of allergies and so a history of allergies or a positive allergy evaluation strengthens the likelihood that one of these conditions is behind the cough.

Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPR) are conditions associated with the leakage of stomach contents into the esophagus.  In GERD, stomach acid refluxes into the lower esophagus causing irritation and damage.  Exposed nerves in the esophagus can cause cough as well as pain (heartburn).  In LPR, stomach contents may reach to the top of the esophagus causing direct irritation of the throat and possible sinuses.  The throat and upper airway are lined with cells that produce mucous as well as cells that have hair-like projections or cilia that sweeps the mucous to the back of the throat where it is swallowed.  Acid and protein-destroying enzymes in the refluxed stomach contents inflame and  damage the hair cells, hindering the ability to clear mucous.  The result is pooling of mucous in the back of the throat and recurrent cough to clear it.  It is estimated that 50% of patients with LPR have no other symptom of their condition other than cough and is therefore frequently missed.   GERD and LPR should be suspected if an evaluation for allergies, asthma, and sinus disease is negative and the cough fails to respond to conventional treatment.

Hypoallergenic Dogs and Other Mythological Creatures

When talking with a patient in our allergy clinic, so often the response to my question,  “Are there any pets in the home”, is “yes, a dog, but it is a hypoallergenic dog”.   I also hear, “My breed of dog does not have fur, it has hair”.  The idea being that, since people are allergic to dog “fur”, having a dog with hair rather than fur avoids the potential problem of dog allergy.

So is there such a thing as a hypoallergenic dog?  Are Poodles and Terriers really less allergenic than Golden Retrievers and Springer Spaniels?   A recent study published in the American Journal of Rhinology & Allergy was conducted to answer this question.

In this study, an Internet search was conducted to identify breeds frequently cited as being hypoallergenic. Dust samples were then collected from homes with a variety of both pure bred and mixed breed dogs.  Researchers have identified Canis familiaris 1 as the allergenic protein (allergen) responsible for dog allergy and the amount of this protein in the dust samples collected from the homes was compared between breeds believed to be hypoallergenic versus the non-hypoallergenic breeds.

Their results?  There was no difference in the amount of allergen shedding by dogs classified as hypoallergenic. The researches concluded that clinicians should advise patients that they cannot rely on breeds deemed to be “hypoallergenic” to in fact deposit less allergenic material throughout the home.

So like the unicorn, the hypoallergenic dog with hair rather than fur is likely a mythological creature, frequently found in word-of-mouth fairy tales and Internet sites, but yet to be found in pet stores.

Children born into a home with pets have lower levels of allergic antibodies

A study reported in an upcoming issue of The Journal of Allergy and Clinical Immunology (JACI), evaluated  the level of allergic antibodies  from birth to 2 years of age in children born into households that kept a pet cat or dog.

Using the population-based Wayne County Health, Environment Allergy and Asthma Longitudinal Study (WHEALS) birth cohort from southeastern Michigan, they analyzed one to four measurements of total IgE in  1,187 infants collected from birth to 2 years of age. Effects of prenatal dog and cat exposure on the shape and pattern of IgE throughout early life were then assessed.

Overall, children from homes with pets had a total IgE  that was an estimated 28% lower then children from  homes without pets. This protective effect of pet exposure was stronger within children born by caesarean section. It is hoped that future studies to  understand the potentially protective effect of prenatal pet exposure will lead to new treatments.

Parents should be aware that other studies have shown that, once a child has become sensitized (“allergic”) to cat or dog  dander, further exposure to a pet can lead to  more severe allergy and asthma symptoms.

It it a Cold, Sinus Infection, or Allergy?

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

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

Where is all that yellow pollen coming from?

Anyone living in Phoenix will have noticed a coating of  bright yellow on neighborhood streets, parked cars, sidewalks, and yards this spring. It’s everywhere.   So what is it?  And perhaps more important, “Does it cause allergies?”  In April through May the answer is usually the Palo Verde tree.  Palo Verde (which is Spanish for green pole, named for it’s green trunk and branches) is the state tree of Arizona and produces a conspicuous bright yellow flower in the spring.  As to causing allergies, the Palo Verde tree is one exception to the rule.   Pollen in the air causes allergy symptoms: runny nose, itchy, watery eyes, stuffy nose, congestion, etc.   As a rule, plants that go to the trouble to produce beautiful, fragrant, conspicuous flowers do so to attract  insects or birds which they rely on to distribute there pollen to distant plants.    These flowers contain a heavy, sticky pollen designed to stay put in the flower until carried away by bees and the like, and so very little is in the air to cause allergy symptoms.    On the other hand, plants that rely on the wind to carry their pollen around produce small, inconspicuous flowers, but lots of light, dry pollen that floats easily in the breeze and to your nose and eyes.   Palo Verde is an insect pollinated tree and therefore should not be a major allergen.  However, as can be witnessed on the sidewalks and streets of  Ahwatukee, Chandler, and Tempe this spring, there are so many trees producing  flowers that the sheer volume causes pollen to find it way into the air, particularly when the wind blows.