Go to our "CLOSINGS" tab on our website to see our updated Coronavirus Policy

Blog

Histamine Fish Poisoning

 

Histamine is the chemical that is responsible for most allergy-related symptoms. It is usually stored inside cells called mast cells.  When one is exposed to allergens that he or she has been previously sensitized to, (e.g., pollens, dust mites, molds, animals, certain foods), the preformed specific antibodies react with their proteins (i.e., antigens) which cause a release of histamine and other similar substances from the mast cells into the tissues of the body.  These chemicals in turn trigger various symptoms such as itching, sneezing, wheezing, coughing, runny nose, watery eyes, nasal congestion, post-nasal drip, etc.

Fish is one of the most common foods that cause food allergies.  Sensitive individuals may experience allergic reactions after consuming fish.  The classic mechanism of this type of allergic reaction is caused by antigen-antibody interactions.  However, there are some people who are not sensitized or allergic to fish but can experience similar symptoms after eating fish.  In these individuals, the symptoms are brought on by a different mechanism.

Many types of fish naturally contain a chemical called histidine.  When the fish are not properly stored and refrigerated, bacteria overgrowth occurs in and on the fish.  These bacteria release an enzyme called histidine decarboxylase which converts the naturally occurring histidine in the fish to a chemical called histamine.  The enzyme is resistant to freezing and heating and can persist even after the bacteria are eliminated by normal cooking techniques. The resulting high levels of histamine cause the same symptoms as an allergic reaction, but the underlying mechanism is a type of toxicity rather than a true allergy.

This condition used to be called scombroid fish poisoning, as fish belonging to Scombridae family (e.g., tuna, mackerel, marlin, swordfish) were originally implicated.  Later, many other non-scombroid fish such as mahi-mahi, sardine, herring, anchovy and bluefish were also found to cause this condition. The preferred current terminology is called “acute histamine toxicity.”

The symptoms usually begin 30 minutes to 2 hours after eating the fish.  The most common manifestations may include:

  1. Generalized itching
  2. Reddish rash over the neck, upper torso, and/or upper extremities
  3. Throbbing headache
  4. Nausea, vomiting, abdominal cramps, and/or diarrhea
  5. Palpitations and/or dizziness
  6. Anxiety and/or chest tightness
  7. Swelling of the face and/or the tongue
  8. Difficulty in breathing

The diagnosis is usually made from the patient’s history.  The appearance of the fish is sometimes described as honeycombed. Some affected individuals also experience a sharp, metallic, bitter, and peppery taste while eating the fish.  Laboratory tests are usually not helpful as histamine is rapidly degraded and cannot be detected in blood or urine samples within 1 to 2 hours after the onset of symptoms. The presence of a specific IgE antibody in the blood to the fish usually indicates an allergic reaction and not a toxic reaction due to the high levels of histamine.  Clusters of individuals exhibiting similar symptoms after eating the same meal generally points more to histamine poisoning rather than an allergic reaction.

The treatment of this condition involves medications that focus on the relief of symptoms. Antihistamines [H-1 blockers (e.g., Benadryl, Claritin, Allegra, Zyrtec) along with H-2 blockers (e.g., Zantac, Tagamet)] are useful in relieving the itching and rash.  Corticosteroids may be appropriate in certain more severe situations. Bronchospasm which may cause wheezing, shortness of breath, chest tightness, and/or coughing can be treated with albuterol inhalations. Rarely, some people may also need intravenous hydration.  Fortunately, most cases of histamine toxicity are self-limited and the symptoms often resolve spontaneously within 6 to 8 hours.

The prevention of acute histamine toxicity requires proper and continuous refrigeration of fish until the time of cooking.  This should prevent bacterial overgrowth and likewise the conversion of histidine to histamine.

The board certified allergists at Black and Kletz Allergy have 3 convenient locations [Washington, DC; McLean, VA (Tysons Corner, VA); Manassas, VA] in the Washington, DC metropolitan area.  The allergy doctors have been trained in providing allergy care for both adults and children.  They in fact have been diagnosing and treating adults and children with allergies for more than 50 years.  They will promptly answer any questions you may have regarding food allergies, food sensitivities, food toxicities, and related disorders.  The allergy specialists can also help you with other allergic conditions such as asthma, hives, swelling episodes, insect sting allergies, medication allergies, contact dermatitis, generalized itching, eczema, sinus disease, anaphylaxis, eosinophilic disorders, and immune disorders.

All 3 offices of Black & Kletz Allergy offer on-site parking.  The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between our McLean office and the Spring Hill metro station on the silver line.  Please call our office to schedule an appointment or alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day.

Grass-Induced Allergic Reactions

 

As we enter the grass season in the Washington, DC, Northern Virginia, and Maryland metropolitan area, it is interesting to note that grasses can cause a multitude of symptoms.  These symptoms may vary from mild to severe and are most notable from the months of May through July in the mid-Atlantic region.  Grasses have been implicated in a variety of disorders ranging from allergic rhinitis (i.e., hay fever), allergic conjunctivitis, asthma, urticaria (i.e., hives), pruritus (i.e., generalized itching), angioedema (i.e., swelling episodes), and anaphylaxis.

The most common disorder caused by exposure to grasses is allergic rhinitis.  Individuals with this condition experience symptoms which may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, sore throat, sinus congestion, sinus headaches, fatigue, and/or snoring.

Allergic conjunctivitis is manifested by itchy eyes, watery eyes, swollen eyes, and/or redness of the eyes.  It is not unusual for individuals with allergic conjunctivitis to experience the feeling of their eyes sticking together from copious amounts of discharge from the eyes.  Rarely, photophobia (i.e., sensitivity to light) may occur in severe cases.

Grasses may also exacerbate asthma symptoms in asthmatic patients.  These patients may experience wheezing, shortness of breath, coughing, and/or chest tightness when exposed to grass pollen.  Many of these individuals find it even more difficult to exercise outside when the grass pollen count it high. Such individuals should be encouraged to minimize their exposure to grass pollen as asthma may be life-threatening in severe cases.

Occasionally grass-allergic patients may develop itchy hives when exposed to high levels of grass pollen and/or when an individual’s skin comes in contact with grass.  These highly grass-allergic patients should be advised to avoid contact with grass, as occasionally the hives can progress to more severe life-threatening symptoms. People who play sports on grassy areas are particularly at risk for this type of reaction.

Similar to patients that develop hives on contact with grasses is a condition where individuals develop generalized itching of their skin without the accompanying rash or hives.  These patients should take the same precautions as the allergic individuals who develop hives from grass exposure.

Another related disorder that may occur upon exposure to grass is called angioedema.  Individuals with this entity may develop swelling of different body parts that either come in direct contact with grasses or are exposed to grass pollen by indirect contact.  Angioedema is a very serious sign, particularly since the swelling may occur internally, such as in the throat, which may obstruct an individual’s breathing. Patients with this disorder should be prescribed and taught how to use a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick).  If used, the patient is to go immediately to the closest emergency room.

On rare occasions a highly grass-sensitive individual may be exposed to an abundance of grass or grass pollen and develop anaphylaxis.  Activities that cause grass stains on the skin (e.g., football, rugby) are more likely to cause anaphylaxis then other activities where hard direct physical contact with grass is not common (e.g., tennis, basketball).  In any case, anaphylaxis is a medical emergency and anyone with anaphylaxis should be treated with epinephrine and be followed up immediately at the closest emergency room. It is imperative that these individuals carry a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick).

As one can see from the examples above, grasses may cause many different symptoms among a variety of conditions.  The symptoms may be mild, moderate, or severe. The board certified allergists at Black & Kletz Allergy have been treating individuals with grass allergies for over 50 years.  If you suffer from any of the symptoms above in the Spring or Summer, please call our office for an allergy consultation in order for us to determine if you have grass or other allergies that may cause any of the symptoms above.  We have 3 offices in the Washington, DC, Northern Virginia, and Maryland metropolitan area with office locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at each location and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line.  Black & Kletz Allergy specializes in treatment of both pediatric and adult patients.  Alternatively, to schedule an appointment, you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergists at Black & Kletz Allergy pride themselves in providing superior allergy and asthma care in a professional and compassionate environment.

Exercise-Induced Asthma

 

“Exercise-induced asthma” or “exercise-induced bronchospasm” is a condition in which individuals develop asthma symptoms only when exercising.  The bronchial tubes become narrowed making it difficult to move air out of the lungs. If one has chronic asthma however, one can still have their asthma triggered by exercising, but in addition, their asthma may be exacerbated by other factors such as allergies (e.g., dust mites, cockroaches, pets, molds, pollens), upper respiratory tract infections, cold air, hot air, increased or decreased humidity, cigarette smoke, diesel fumes, strong scents, and other irritants.  Many individuals with exercise-induced asthma are not diagnosed in a timely fashion since many clinicians do not recognize the condition.  It may go undiagnosed for years and the symptoms may be attributed to poor exercise tolerance or just being “out of shape.” Children often avoid exercise without telling anyone that exercise is bothersome.

The classic symptoms of exercise-induced asthma include wheezing, chest tightness, coughing, and/or shortness of breath.  Individuals with exercise-induced asthma generally develop asthma symptoms within 5 to 20 minutes after beginning their exercise.  It is also typical for them to have symptoms after they stop exercising. Exercise-induced asthma tends to occur more often on cold, dry days rather than on warm, humid days.

The diagnosis of exercise-induced asthma is made by way of a comprehensive history and physical examination in conjunction with pulmonary function tests.  It is also helpful for the patient to have a peak flow meter to use at home so that he or she can measure their outflow of air before and after exercise. A decrease in the peak flow while or after exercising helps the allergist determine if the patient is exhibiting an exercise-related decrease in air flow.  Other conditions that should be ruled out include cardiac disease, GERD (i.e., acid reflux), chronic sinusitis, chronic obstructive pulmonary disease [COPD (e.g. chronic bronchitis, emphysema)], anxiety attacks, and vocal cord dysfunction, to name a few.

Although patients with exercise-induced asthma develop symptoms upon exercise, it is important that the patient understand that with treatment, it is usually possible to exercise.  In fact, exercise is generally encouraged in almost all individuals with this condition. There are many examples of famous athletes who have won Olympic Gold Medals, football championships, etc. that have had exercise-induced asthma.  It may be helpful for the some individuals to get an asthma action plan from their allergist so that he or she knows exactly what to do to treat or prevent the symptoms. In addition, the use of a short-acting beta-2 agonist rescue inhaler medication such as albuterol e.g., (Proventil, Ventolin, ProAir, Xopenex) about 30 minutes before exercise may prevent symptoms from developing.  If needed, the inhaler may also be used after symptoms occur if this plan is discussed and agreed upon with an allergist. There are other medications which can be utilized such as Singulair (i.e., montelukast) which have been shown to help prevent the symptoms of exercise-induced asthma. More severe cases may need inhaled corticosteroids in order to control the condition. In addition to medications, warm-ups and cool-downs may mitigate or even prevent symptoms.  It is also prudent to avoid exercising in the high pollen season if the individual is allergic to pollens. Avoidance of exercise is also recommended if the person is experiencing an upper respiratory tract infection or if the air is cold and dry.

The board certified allergy specialists at Black & Kletz Allergy are always available for our patients to ask any questions that they may have regarding asthma or allergies.  We have been treating pediatric and adult patients with exercise-induced asthma, as well as patients with chronic asthma, allergic rhinitis (i.e., hay fever), allergic skin conditions such as eczema and hives, insect sting allergies, medication allergies, eosinophilic disorders, other allergic maladies, and immune disorders for more than 5 decades.  We have 3 office locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices offer on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  If you would like to be evaluated today for exercise-induced asthma or any other allergic or immunologic problem, please call us today.  You may also click Request an Appointment instead and we will respond to your request within 24 hours by the next business day.  The allergists at Black & Kletz Allergy pride ourselves in providing the highest quality asthma and allergy care in the Washington, DC metro area.

Mold Allergies and How They Can Affect You

 

Molds are fungi that grow in the form of multicellular filaments that are called hyphae.  Fungi that grow in a single celled environment are called yeasts. Mildew is also a fungus that closely resembles mold; however, the color of mildew tends to be white whereas mold tends to be black, blue, green, or red.  Regardless, mold, mildew, and yeast can all play havoc to individuals who are either sensitive or allergic to them. Mold and mildew produce unwanted odors that many individuals find offensive or downright problematic as they can cause ailments to those exposed.

The physical appearance of molds usually is recognized by a discoloration and fuzziness presentation.  Molds can be found anywhere outdoors or indoors and are typically found on old or expired foods, rotten decaying debris (e.g. wet fallen leaves in the Fall, compost piles, grasses, rotting wood), and in places where increased moisture or water exists (e.g., basements, bathrooms, kitchens).  Molds produce mold spores which are their tiny microscopic reproductive structures. The size of a mold spore generally ranges from 3 to 45 microns in diameter which is less than half the width of a human hair. These spores begin to germinate and multiply. The spores multiply by producing reproductive hyphae.  They and are released into the air and given their microscopic size, they are able to float in the air sight unseen. Mold spores can grow in any environment with a constant source of moisture. There are even types of molds that can survive in very arid conditions such as deserts. During the growth process, mold spores begin to undergo chemical reactions that allow them to consume nutrients and further multiply.  These chemical reactions cause fumes to be released into the atmosphere. These fumes are responsible for the unpleasant musty mold odor. Of note, there are over 400,000 types of molds.

In the Washington, DC, Northern Virginia, and Maryland metropolitan area, the numbers of mold spores in the environment are generally higher than in many other parts of the country.  Washington, DC was built on a swamp. In addition, the Washington, DC metropolitan area tends to have a fairly high relative humidity when compared to many other areas of the U.S.  This combination exposes the residents of our metro area to a higher concentration of molds. In turn, it places us at a greater risk to develop mold allergies and other non-allergic mold-related conditions that may occur in sensitive individuals.  Non-allergic mold-related illnesses may result from either the growth of pathogenic molds within the body or from the effects of ingested or inhaled toxic compounds called mycotoxins which are produced by molds. The molds that produce mycotoxins can pose serious health risks to humans and animals.  Some studies claim that exposure to high levels of mycotoxins can lead to neurological problems and prolonged exposure may be particularly harmful. The research on the health effects of these types of molds has not been conclusive. The term “toxic mold” refers to molds that produce mycotoxins, such as Stachybotrys chartarum and not to all molds in general.

Mold allergies are very common and the symptoms are the same as other causes of hay fever (i.e., allergic rhinitis) and/or asthma.  The symptoms may include runny nose, sneezing, nasal congestion, post-nasal drip, itchy nose, itchy eyes, watery eyes, redness of the eyes, sinus headaches, wheezing, coughing, chest tightness, and/or shortness of breath.  Symptoms often worsen when a sensitive individual is in a damp or moldy environment such as a basement or crawl space.

Approximately 1-2% of patients with asthma have an allergic or hypersensitive reaction to a type of mold known as Aspergillus fumigatus.  Similarly, 2-15% of children with cystic fibrosis have the same reaction to this mold.  Aspergillus fumigatus is generally found in the soil.  Asthmatics and cystic fibrosis patients with that react to this mold have a condition called allergic bronchopulmonary aspergillosis (ABPA).  ABPA is more common in adolescents and male individuals.  The symptoms of ABPA are very much the same symptoms of asthma; however they may also cough up mucus with brownish flecks and may also have a mild fever.  The diagnostic workup may include radiographic studies, bloodwork, sputum culture, pulmonary function tests, and allergy skin testing. The treatment may involve the use of oral corticosteroids and/or antifungal medication in addition to the typical asthma medications such as corticosteroid inhalers, long-acting beta agonists, leukotriene antagonists, short-acting beta agonists, and/or theophyllines.

The diagnosis of mold allergy is done by a board certified allergist who will do a comprehensive history and physical examination.  Allergy testing to molds can be done via skin testing or blood testing.

Treatment of mold allergy should always begin by trying to prevent exposure to mold.  There are many things that can be done in one’s home or workplace that may help reduce one’s exposure.  Reducing the humidity, fixing any leaks, wearing a mask when doing yardwork, limiting outdoor activities when the mold counts are high, using air conditioning with a HEPA filter, installing a dehumidifier, and removing carpeting from places where it can get wet are some of the ways to reduce mold exposure.  The allergist may prescribe allergy medications (e.g., antihistamines, decongestants, nasal corticosteroids, nasal antihistamines, eye drops, leukotriene antagonists, asthma inhalers) to help alleviate one’s symptoms. Allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization) are extremely effective in the treatment of mold allergy.  They are effective in 80-85% of the patients who take them. They have been utilized in the U.S. for more than 100 years and get more to the root of the underlying problem by causing an individual to develop protective antibodies against mold as well as other allergens (e.g., pollens, dust mite, pets, cockroach).

The board certified allergists at Black & Kletz Allergy have 3 locations in the Washington, Northern Virginia, and Maryland metropolitan area.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices have on-site parking and the Washington, DC and McLean, VA offices are also Metro accessible.  The McLean office has a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line.  The allergy doctors at Black & Kletz Allergy diagnose and treat both adult and pediatric patients.  To make an appointment, please call our office or you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy specialists at Black & Kletz Allergy have been helping patients with mold allergies and other causes of hay fever, asthma, hives, sinus disease, eczema, food allergies, medication allergies, insect sting allergies, and immunological disorders for more than half a century.  If you suffer from mold allergies or any other type of allergies it is our mission to improve your quality of life by reducing or preventing your undesirable and irritating allergy symptoms.

Chronic Sinusitis

 

Sinuses are air filled cavities within the facial bones.  They are located behind the forehead (e.g., frontal), behind the eyes (e.g., ethmoid, sphenoid), and behind the cheek bones (i.e., maxillary).  The membranes lining the inside of these cavities secrete mucus which normally drains into the nasal cavity through small openings.

When the nasal cavity becomes inflamed (i.e., rhinitis) either due to allergen or irritant exposure or due to microbial infections, the pores through which the sinuses drain can become clogged.  This clogging of the pores may lead to the back up of secretions within the enclosed sinus cavities. Accumulation of mucus within the sinuses can result in proliferation of viruses and bacteria and can lead to chronic sinus infections (i.e., chronic sinusitis), defined as persisting sinus-related symptoms lasting for more than 12 weeks.

The common symptoms of a chronic sinus infection or chronic inflammation of the sinuses may include facial pressure/pain, headache, discolored nasal and post-nasal secretions, cough and/or malaise.  The diagnosis of this condition requires a detailed history of onset and progression of specific symptoms, a physical examination, and imaging studies such as sinus X-rays and/or CT scans.

Some common medical treatments of chronic sinusitis are as follows and may include combinations of the treatment regimens listed below:

  1. Saline nasal sprays and/or irrigations:  These are useful in the mechanical clearance of irritants, allergens, and microbes from nasal and sinus cavities.  They are inexpensive and easy to use although they can cause some discomfort during usage is some individuals. Their main use is as an adjunctive therapy to other more specific treatments.
  2. Topical steroid sprays:  These are considered first-line treatments for chronic sinusitis.  They act by controlling inflammation and reducing the swelling of the tissues and decreasing excessive secretions. They are useful both in chronic sinusitis with nasal polyps and chronic sinusitis without polyps.  They are widely available and easy to use. Some of the potential drawbacks of topical steroids may include a burning sensation of the nose, headaches, sore throat, and/or occasional nosebleeds.
  3. 3. Topical antibiotics:  These are sometimes useful in local treatment of bacterial infections.  The effects are usually short-lived. These agents are not currently recommended for routine use but offer the potential for improved directed treatment as the ability to identify the effects of specific pathogens evolves.
  4. 4. Surfactants:  Some clinical trials demonstrated benefits of surfactants in the control of biofilms.  Surfactants are widely used as detergents, emulsifiers, foaming agents and dispersants in the cosmetics, hygiene, food, and oil industries. Their use in the medical field is also common, particularly within the field of wound care.  Many wound cleansers contain surfactants and help in the enhancement of wound closure. Their use however can be associated with considerable discomfort and their role in management of chronic sinusitis is not clearly determined at this time.
  5. Oral steroids:  They can effectively reduce inflammation and are especially useful for shrinking nasal polyps, though they also may result in the multisystem improvement of symptoms.  Due to their significant systemic side effects (e.g., weight gain, endocrine dysfunction, thinning of bones, peptic ulcers, cataract formation, depression), they are utilized judiciously and only for short periods of time.
  6. Oral antibiotics:  These are often used to control acute flare-ups of bacterial infections.  Some classes of drugs such as macrolides [(e.g., Biaxin (clarithromycin), Zithromax (azithromycin), erythromycin] also have anti-inflammatory effects in addition to their antibacterial properties.  Potential side effects include gastrointestinal distress and possible development of bacterial resistance on repeated usage.
  7. Biologicals:  As more research sheds light on specific inflammatory molecules and pathways driving the inflammation in chronic sinusitis (i.e., phenotypes and endotypes), biological medications can offer targeted and more effective treatment options.  The potential advantages are the reduced need for oral or topical steroids as well as the need for sinus surgery. A few of these agents are currently being used for the control of asthma but none of them have been currently approved for chronic sinusitis.

Preventive measures for chronic sinusitis include identification of specific allergen sensitivities by allergy testing by a board certified allergist.  Allergy testing can be done by skin testing or blood testing depending upon the circumstance and age of the patient.  The aggressive treatment of allergic seasonal and/or perennial rhinitis (i.e., hay fever) promotes proper sinus drainage and improves upper airway function.

The board certified allergists and immunologists at Black & Kletz Allergy have 3 convenient office locations in the Washington, DC, Northern Virginia, and Maryland  metropolitan area.  Our allergists have been treating chronic sinusitis as well as acute sinusitis and other sinus-related conditions for many years.  Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  If you or someone you know has an allergic condition that predisposes you to sinus problems or sinus infections, please make an appointment so that we may help you.  Alternatively, you can click Request an Appointment and we will respond to your request within 24 hours by the next business day.  The allergy specialists at Black & Kletz Allergy have been treating both adults and children in the Washington, DC metropolitan area for allergies, asthma, sinus disease, and immunologic disorders for more than 50 years and would be happy to provide allergy and sinus relief for you in a caring and professional atmosphere.

Chronic Cough

 

The common cold is the most common cause of a cough.  It usually subsides spontaneously after 2 to 3 weeks. However, a persistent cough may be the first sign of a more serious disease process.

A chronic cough (defined as lasting for more than 8 weeks in adults and more than 4 weeks in children) is one of the most common presenting complaints in ambulatory medical clinics across the country, according to the Centers for Disease Control (CDC).

Though they are a number of different causes for chronic cough, 4 conditions account for the vast majority of cases:

  1. Upper airway cough syndrome (i.e., UACS, previously called “post-nasal drip syndrome”)
  2. Gastroesophageal reflux disease (i.e., GERD or acid reflux) / Laryngo pharyngeal reflux (i.e., LPR)
  3. Asthma
  4. Eosinophilic bronchitis.

Additional causes may include:

  1. Side effects of medications such as ACE (i.e., angiotensin converting enzyme) inhibitors which are typically utilized to treat high blood pressure
  2. Tobacco use
  3. COPD (i.e., chronic obstructive pulmonary disease) which encompasses both emphysema and chronic bronchitis
  4. Sleep apnea

An excessive or chronic cough can seriously impair the quality of life of an individual and lead to vomiting, muscle pain, rib fractures, urinary incontinence, fatigue, syncope, and/or depression.  Some of the “red flags” indicating a more serious issue may include an association of a cough with fever, weight loss, hoarseness, and/or blood in the sputum. When a cause is not obvious, a chest X-ray is usually obtained to rule out common infections, inflammatory conditions, and/or tumors.

UACS:  It is the most common cause of chronic cough.  The condition is a result of inflammation of the tissues inside the nasal cavity (i.e. allergic or non-allergic rhinitis).  The symptoms may include runny nose, nasal congestion, sneezing, and/or post-nasal drip but their absence does not exclude UACS.  Physical examination may reveal a pale and moist lining of the nasal cavity, swelling of turbinate tissues, redness and/or a cobblestoning appearance in the back of the throat.  Apart from specific treatments of identifiable causes, the symptoms can be relieved by a combination of decongestants, antihistamines, nasal sprays (e.g., saline, corticosteroids, antihistamines, anticholinergics).  Improvement in symptoms can take a few weeks after the initiation of treatment.

Asthma and/or COPD:  Close to one fourth of all cases of a chronic cough may be due to asthma.  The diagnosis is suspected when a cough is associated with chest tightness, shortness of breath, and/or wheezing.  However, a cough may be the only manifestation of asthma in some instances (i.e., cough variant asthma). The diagnosis is established by spirometry before and after the inhalation of a bronchodilator medication.  If inconclusive, asthma can be provoked by inhalation of a medication called methacholine, as part of a diagnostic work-up. Treatments may include inhaled corticosteroids, inhaled bronchodilators, oral anti-inflammatory medications, and rarely short courses of oral corticosteroids.  Cough and other asthma symptoms usually respond to therapy in less than a week.

Signs and symptoms suggestive of asthma may also occur in persons with COPD. Spirometry is diagnostic, and purulent sputum production may also be present. Treatment usually includes an inhaled bronchodilator, inhaled anticholinergic, inhaled corticosteroid, and occasionally a 1-2 week course of oral corticosteroids (with or without antibiotics).

Non-asthmatic eosinophilic bronchitis:  This condition is characterized by a chronic cough without evidence of airflow limitation on pulmonary function tests but the presence of eosinophils in the sputum.  This condition does not respond to inhaled bronchodilators but does respond to inhaled corticosteroids. Avoidance strategies are recommended when the inflammation is due to occupational exposure or inhaled allergens.

GERD/LPR:  Suspicion for these conditions arise when symptoms of heartburn, regurgitation, sour taste, and/or hoarseness are associated with a chronic cough. Consensus guidelines recommend empiric therapy for at least eight weeks in conjunction with lifestyle modifications such as dietary changes and weight loss.

Obstructive sleep apnea:  Obstructive sleep apnea usually presents with night time snoring, restless sleep, and/or daytime somnolence, however, cough can be a manifestation is some cases.  CPAP machines help to relieve the obstruction by forcing air through the upper airways.

ACE inhibitors:  A cough may begin as a side effect in about 10 to 20% of patients receiving these medications and is more common in women.  The cough may appear several months after beginning an ACE inhibitor which often makes it more difficult to diagnose. The only treatment of a cough caused by an ACE inhibitor is the discontinuation of the ACE inhibitor.  After discontinuing the ACE inhibitor, it may take 1-2 months for the cough to subside.

Children:

The most common causes of a chronic cough in children 6-14 years of age are asthma, protracted bacterial infections, and UACS.  Bacterial bronchitis generally requires a 2 week course of an antibiotic such as Augmentin in children who are not allergic to penicillins or clavulinic acid, the components of Augmentin.  UACS is rare in children younger than 6 years of age. Exposure to tobacco smoke, pets, and environmental irritants should be minimized. Of note, rarer conditions such as foreign body aspiration, congenital malformations, and certain immune disorders can also cause a chronic cough in children.

The board certified allergists at Black & Kletz Allergy have been diagnosing and treating chronic coughs in both adults and children in patients in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  Patients are carefully screened for allergies, asthma, GERD, upper respiratory tract infections, medication usage, sinus disease, and other causes of a chronic cough.  Black & Kletz Allergy has 3 offices in the Washington, DC metro area with locations in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices have on-site parking and the Washington, DC and McLean, VA offices are Metro accessible.  We offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  If you suffer from a chronic or intermittent cough, please call us to make an appointment at one of our conveniently located offices.  Alternatively, you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy are confident that we will be able to help you identify the cause of your cough as well as treat the underlying condition in order to terminate your cough.

Sinus Symptoms that are Common in the Spring

Now that it is officially Spring, many people will begin to feel the unwanted allergic symptoms of hay fever (i.e., allergic rhinitis).  In the Washington, DC, Northern Virginia, and Maryland metropolitan area the allergens responsible for these symptoms are mostly due to the tree and grass pollens.  If someone continually notices allergic symptoms throughout the year, then they may also be allergic to other allergens such as dust mites, molds, weed pollen, cats, dogs, and/or cockroaches.  The typical allergic symptoms that are characteristic for this time of year may include some or all of the following: runny nose, nasal congestion, post-nasal drip, sneezing, itchy nose, itchy eyes, watery eyes, puffy eyes, redness of the eyes, dark circles under the eyes, itchy throat, snoring, wheezing, shortness of breath, chest tightness, coughing, fatigue, headaches, sinus congestion, and/or sinus pain.

In many individuals, their underlying environmental allergies predispose them to sinus issues.  Patients with sinus problems should be skin tested for allergies to environmental allergens by an board certified allergist to see if there is an underlying allergy that is predisposing them to sinus symptoms.  In some, it is just a matter of experiencing mild sinus congestion, nasal congestion, post-nasal drip, and/or sinus pain.  Often there is associated discolored nasal mucus with colors ranging from light yellow to green to brown. In others, the sinus symptoms can be debilitating resulting in a poor quality of life.  Many develop sinus infections (i.e., sinusitis) as a result of their underlying allergic diathesis.  There are 3 types of sinusitis: acute sinusitis, chronic sinusitis, and recurrent sinusitis.  Below each one is discussed a little further:

Acute sinusitis:  This is the most common type of sinus infection.  It is usually caused by the development of an infection with either a virus, bacteria, fungus, or rarely a parasite.  Most cases of acute sinusitis are caused by viruses. Many of these infections are self-limited and they will resolve on their own.  It may be helpful to use saline irrigation, antihistamines, decongestants, mucus-thinning medications, nasal sprays, and/or over the counter analgesics in selected patients.  It is however not uncommon for a viral acute sinus infection to be secondarily infected with a bacteria. If this occurs, it is important that one see their board certified allergy doctor, as it is usually necessary in this case to treat the bacterial acute sinus infection with a course of antibiotics.  In recalcitrant cases, it may be necessary to use longer courses of antibiotics to completely rid the sinuses of the causative bacteria.

Chronic sinusitis:  This type of sinus infection is not as common as an acute sinus infection and usually results from a non-complete resolution of an acute sinus infection.  Chronic sinus infections are more difficult to treat, however, they can be eradicated most of the time. They are usually caused by bacteria or a fungus. The symptoms that one exhibits when they have a chronic sinus infection may be the same as with an acute sinus infection, however, the symptoms may be much more indolent.  It is therefore not uncommon for individuals with chronic sinus infections to only have one or more of the following non-specific symptoms: cough, sore throat, chest congestion, wheezing, and/or headaches. The diagnosis of chronic sinusitis may be difficult and elusive due to its non-specific symptoms that often present in these individuals.  The diagnosis is generally made by obtaining a CT scan of the sinuses. The treatment is usually a prolonged course of antibiotics for generally a 30 day course. It may be necessary to repeat another prolonged course of antibiotics if the symptoms resolve and then re-occur. In rare instances, sinus surgery may be needed. If one suspects a chronic sinus infection, it is necessary to see your allergist, so that treatment can ensue.

Recurrent sinusitis:  This type of sinusitis manifests itself as an acute sinus infection that is treated and re-occurs usually within 1-2 months of completing a course of antibiotics.  It can continue to re-emerge and it is not uncommon for some patients to have 6-8 sinus infections per year! In patients with recurrent sinusitis, it is imperative that they seek advice of a board certified allergist/immunologist like the ones at Black & Kletz Allergy who have decades of experience in diagnosing and treating these types of sinus problems.  In individuals with recurrent sinusitis, it is important for the allergist to do an immune workup, in addition to skin testing for environmental allergies, in order to ascertain if there is an immune deficiency.  If there is an immune defect, then intravenous immunoglobulin or subcutaneous immunoglobulin therapy can be implemented to “reverse” this immunodeficiency and thus prevent further sinus infections.

If you suffer from hay fever (i.e., allergic rhinitis), asthma, or sinus-related symptoms, please call Black & Kletz Allergy and schedule an appointment with one of our board certified allergists.  They specialize in both pediatric and adult allergy, asthma and immunology.  Black & Kletz Allergy has 3 locations in the DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All office locations have on-site parking and the Washington, DC and McLean, VA offices are also Metro accessible.  We also offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  In addition to calling one of our 3 office, you may click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy have been treating allergies, asthma, immune disorders, and sinus disease for more than 50 years.  We use the most current leading-edge diagnostic techniques along with the administration of a variety of medications [i.e., allergy shots (allergy immunotherapy), biologicals, nasal sprays, antihistamines, eye drops, decongestants, leukotriene antagonists, etc.] in order to diagnose and treat each specific patient’s unique condition(s) that ultimately results in an improved quality of life for that individual.  We make it a point to cater specific therapies to each individual’s needs and desires.

Eye Allergies (Allergic Conjunctivitis)

Now that it is March and the Spring has begun, many individuals will experience irritated eyes.  The typical eye symptoms that allergic individuals may notice include itchy eyes, watery eyes, puffy or swollen eyelids, thick sticky discharge, eyelids sticking together especially in the mornings when awakening.  In most cases, tree and/or grass pollen allergy is the cause, however allergies to other allergens such as molds, pets, dust mites, and/or cockroaches may be the allergic cause.

Most individuals with allergic conjunctivitis have associated allergic rhinitis (i.e., hay fever)where they have other symptoms which may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, sinus headaches, sinus pressure, and/or snoring.  Asthmatic individuals may experience increased asthma symptoms in the Spring if they are sensitive to outdoor allergens such as tree pollen, grass pollen, and/or molds.  It is not unusual for some individuals to experience increased asthma, allergic rhinitis, and allergic conjunctivitis symptoms together.

The diagnosis of allergic conjunctivitis begins with a comprehensive history and physical examination by a board certified allergist.  Allergy skin testing or blood testing is usually performed in order to identify if and what the offending allergens are that are causing the allergic eye symptoms.

When evaluating an individual with the symptoms of eye allergies, it is important for the physician to rule out other causes of red eyes or “pink eye.”  Viral, bacterial, and/or parasitic infections of the eye(s) can cause similar symptoms but are treated differently. Chemical irritation or a foreign body can also cause the eyes to become red.  Anterior uveitis, which can be associated with an autoimmune disorder or a sexually transmitted disease, may also cause redness of the eyes. In addition, there is usually “photophobia” which is the pain in the eyes when in a bright environment.  A subconjunctival hemorrhage or bleed may also occur when the capillaries break near the “whites” of the eyes. Some causes of subconjunctival hemorrhages may include trauma, coughing, straining, sneezing elevated blood pressure, diabetes, and/or certain blood thinning medications [e.g.., aspirin, Coumadin (warfarin), Plavix (clopidogrel), Eliquis (apixaban), Pradaxa (dabigatran), Xarelto (rivaroxaban), Brilinta (ticagrelor), Effient (prasugrel), Aggrenox (aspirin plus dipyridamole)].  They can also just occur spontaneously without an apparent cause.

The treatment of allergic conjunctivitis may include the use of various eye drops, oral antihistamines, nasal corticosteroids, leukotriene antagonists, and/or allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization).  Of course, avoiding the offending allergen is the first and primary focus with any allergy, but in most cases, especially if allergic to the pollen in the Spring, it is almost impossible to avoid.  That being said, there are still some avoidance measures that can be practiced in order to limit one’s exposure to pollen. Some of them are as follows:

  1.  Close the windows of your home and automobiles.
  2.  Change your clothes and shower after spending a long time outdoors or after yard work.
  3.  Follow the local pollen count on our website by clicking Today’s Pollen Count.
  4.  Go outdoors after it rains as the pollen count is “washed away” temporarily after the rain.
  5.  Wash the fur of your pet after it comes indoors from the outside.
  6.  Leave your shoes outdoors after being outdoors.
  7.  Begin using nasal sprays and/or antihistamines early in the pollen season.
  8.  Consider allergy shots, as mentioned above, if more severe or persistent symptoms to pollens and/or molds, as they generally are effective in 80-85% of individuals with allergic conjunctivitis and/or allergic rhinitis.

The board-certified allergy doctors at Black & Kletz Allergy are specialists in diagnosing and treating both adults and children with allergic conjunctivitis as well as many other allergic disorders.  Some of these include allergic rhinitis, asthma, sinus disease, eczema (i.e., atopic dermatitis), hives (i.e. urticaria), generalized itching (i.e., pruritus), contact dermatitis (e.g., poison ivy, poison oak, poison sumac), swelling episodes (i.e., angioedema), anaphylaxis, insect sting allergies, food allergies, medication allergies, eosinophilic disorders (e.g., eosinophilic esophagitis), and immunological disorders.  Black & Kletz Allergy has 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We have offices in Washington, DC, McLean, VA (Tysons Corner), and Manassas, VA.  All of our locations offer on-site parking and our Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.

If you suffer from allergies or any of the conditions listed in the above paragraph, please call us in order to schedule an appointment with one of our board-certified allergists.  You may also click Request an Appointment and we will respond within 24 hours by the next business day.  The allergists at Black & Kletz have been helping the residents and visitors of the Washington, DC metropolitan area for more than 50 years and are pleased to help you improve the quality of your life by alleviating those unwanted and annoying allergies and asthma symptoms.