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Allergy to Nonsteroidal Anti-Inflammatory Drugs (NSAID’s)

Nonsteroidal anti-inflammatory drugs (NSAID’s) are a group of medications related to aspirin. The group includes commonly used drugs such as ibuprofen (i.e., Motrin, Advil), naproxen (i.e., Aleve, Naprosyn), diclofenac (i.e., Voltaren), etodolac, (i.e., Lodine), among others. These agents are widely used in order to reduce inflammation (e.g., decrease pain and reduce swelling of joints in various forms of arthritis). They also help reduce fever caused by infections as well as relieve discomfort after injuries.

NSAID’s act by blocking an enzyme called cyclooxygenase-1 (COX-1). Cyclooxygenase-1 acts by producing compounds known as prostaglandins. These prostaglandins are involved in tissue inflammation which results in pain, swelling, and/or fever. Since NSAID’s block the enzyme cyclooxygenase-1, they also inhibit the production of prostaglandins. Thus, NSAID’s will decrease tissue inflammation and reduce pain, swelling, and fever. Aspirin not only blocks the enzyme cyclooxygenase-1, but it also blocks the cyclooxygenase-2 COX-2) enzyme as well. Thus, aspirin also leads to a decrease in tissue inflammation as well as a reduction in pain, swelling, and fever. In addition, aspirin decreases the activity of blood components known as platelets. While platelets are known to promote the clotting of blood, aspirin, on the other hand, helps prevent blood clots due to its antagonistic effect on platelets, which reduces the risk of heart attacks and strokes.

Common side effects of aspirin may include bruising and abdominal pain. Less commonly, a stomach ulcer or stomach bleeding may occur. Very high doses of aspirin may cause confusion or ringing in the ears (i.e., tinnitus).

Aspirin can cause allergic reactions in some individuals. These symptoms may include flushing, generalized itching (i.e., pruritus), hives (i.e., urticaria), swelling (i.e., angioedema), nasal congestion, runny nose, and/or asthma usually within an hour of taking a tablet. These reactions occur in approximately 1% of people receiving aspirin. It should be pointed out that in patients with hives, nasal polyps and asthma, the risk could be as high as 30%. The co-existence of asthma, nasal polyps, and aspirin sensitivity is termed Samter’s triad or aspirin exacerbated respiratory disease (AERD).

The manifestations of aspirin and NSAID sensitivity may include:

Itching, usually generalized
Hives
Swelling of soft tissues such as eyelids, lips, tongue, throat, etc.
Chest tightness, wheezing, coughing, shortness of breath
Dizziness and altered sensorium

Diagnosis:

The diagnosis of NSAID allergy is based mostly on the history of adverse effects within a short time after receiving the drug. There is no reliable blood or skin allergy test for confirming or excluding the sensitivity to aspirin and NSAID’s. The only way to assess aspirin sensitivity is by a graded open challenge under strict medical supervision. Challenge testing is not always necessary, but may be advised in some circumstances in order to prove that sensitivity exists, or to prove the safety of an unrelated medication.

Treatment:

The treatment of NSAID allergy is directed at the relief of symptoms with antihistamines, bronchodilators, and epinephrine in cases of anaphylaxis.

Prevention:

Preventing NSAID reactions involves the total avoidance of aspirin and all cross- reacting NSAID’s. As there are so many brand names of the same medication, and so many types of medications available, accidental exposure to aspirin or NSAID’s may occur. NSAID’s are common ingredients of many over-the-counter painkillers and cold/flu remedies.

If you have ongoing hives, you should avoid aspirin and NSAID’s unless you know that you can tolerate them without a problem. If you are already taking regular aspirin (for example, to prevent heart attack or stroke), or a regular arthritis tablet for the treatment of pain, then you should consult with your primary care physician, rheumatologist, or cardiologist about stopping the aspirin. Your physician may tell you that you do not need to stop taking the aspirin unless your hives clearly get much worse after taking the medicine. If you have had an allergic reaction to one type of NSAID, a challenge with a different drug can be considered if you need to take aspirin or an anti-inflammatory medication for the treatment of arthritis.

Some NSAID’s such as celecoxib (i.e., Celebrex) and meloxicam (i.e., Mobic) predominantly inhibit the cyclooxygenase-2 (COX-2) enzyme rather than the cyclooxygenase-1 (COX-1) enzyme. Thus, they can be taken safely by many patients (but not all), who have aspirin and NSAID sensitivity. Acetaminophen (i.e., Tylenol) and codeine do not usually cross-react with NSAID’s and can usually be taken safely for the relief of fever and/or pain.

Aspirin desensitization is a procedure that could be helpful in some patients with AERD to improve asthma control, inhibit nasal polyp growth, and to enable aspirin therapy for reducing the risk of blood clots in order to protect the heart and the brain.

The allergy specialists at Black & Kletz Allergy see both adult and pediatric patients and have over 5 decades of experience in the field of allergy, asthma, and immunology. If you have or suspect you have a sensitivity or allergy to aspirin, NSAID, or any other medication, please call our office. Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day. We have been servicing the greater Washington, DC metropolitan area for over 50 years and we look forward to providing you with the highest state-of-the-art allergy care in a welcoming and relaxed environment.

Allergies in the Spring Update

Well, it is almost Spring again. If you are one of those individuals with Spring allergies, you know that it is time for those miserable allergy symptoms to reappear unless you do something about it. The primary cause of Spring allergies is the tree pollen, although secondary allergens often include molds. The classic symptoms of Spring allergies may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, sinus headaches, fatigue, itchy eyes, watery eyes, and/or redness of the eyes. In addition, some individuals, especially those with asthma, may also develop or experience worsening of chest tightness, coughing, wheezing, and/or shortness of breath.

The pollination of trees in the Washington, DC, Northern Virginia, and Maryland metropolitan area usually begins in March and generally lasts until early May. It is interesting to note however that the pollination of trees throughout the country has been beginning earlier and earlier as time goes on, particularly in the last 20 years. Tree pollen is now found in the Washington, DC area in early February and occasionally in January when there are unusually warm days. As a result, sensitive individuals are finding themselves bothered by tree pollen much earlier in the year than in the past. Increasing levels of carbon dioxide are being documented every year causing many scientific researchers to believe that climate change is contributing to this trend. Carbon dioxide is the primary gas needed for the growth and development of trees along with nutrients, water, and sunlight. Changes in the climate may impact the pollen seasons of trees, grasses, and weeds by both increasing the amount of pollen produced as well as by extending the duration of the pollen season.

Tree pollination is for all intents and purposes the reproductive season for the trees. Tree pollen grains are released into the atmosphere in order to fertilize the ovules of other trees. Tree pollen is produced and dispersed by the wind throughout the day, but their counts are highest in the morning hours. Birch, oak, cedar, elm, ash, cottonwood, hickory, and maple are the predominant tree pollens in the Washington, DC metropolitan area.

A common fallacy is that if someone has a particular tree (i.e., oak) or many of those specific trees (i.e., oak) in their yard, they are more likely to have allergy problems from those trees if they are allergic to them. This in fact is not true since pollen is disbursed all over the region and it is not unheard of for the pollen to travel over 200 miles. For this reason, people can suffer from tree pollen allergy (i.e., oak) even if they live fairly far away from that nearest tree (i.e., oak).

Another misconception people have is that they are allergic to flowers that bloom in the Spring. These individuals assume that because they are experiencing allergy symptoms in the Spring when the flowers are blooming that they are allergic to the flowers. In reality, the flowers happen to be blooming the same time that the trees are pollinating and the allergy sufferers equate their worsening allergy symptoms with the flowers that they see. It is the tree pollen that is causing their hay fever (i.e., allergic rhinitis and allergic conjunctivitis) symptoms and not the flowers. As a matter of fact, another name for hay fever is “rose fever.” It is called rose fever because roses bloom in the Spring, at the same time tree pollen levels are high. It is interesting that the names hay fever and rose fever are also inaccurate in that there is no allergy to hay or roses and there is also no fever associated with the condition.

The diagnosis of Spring allergies begins with taking a comprehensive history and performing a complete physical examination. Allergy testing by either skin testing or blood testing is performed in order to identify the offending allergen. Once the allergen is identified, preventive measures are recommended in order to reduce the exposure to that allergen.

Some measures to diminish exposure to pollen which helps lessen symptoms may include the following:

Track the the local pollen counts on our homepage by clicking Today’s Pollen Count and avoid outside activities on days with high pollen counts.
Avoid activities in the early morning since the pollen counts are at their highest early in the mornings.
Plan to go outdoors after it rains as the pollen count is lower after a rain.
Shower before going to bed in order to wash the pollen off.
Close your windows in your house and automobiles, as well as run your air conditioning in order to help prevent pollen exposure.
Leave your shoes outside so you do not bring the pollen into the home.
Change one’s clothes and wash them after being outside.
Wash your pet before the animal comes inside.

The treatment of Spring allergies usually includes prevention of the offending allergen(s), therapy with medications, and/or allergy immunotherapy (i.e., allergy shots, allergy injections, allergy desensitization, allergy hyposensitization). There are a variety of medications that may be used in order to treat Spring allergies. Oral antihistamines, oral decongestants, oral leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, ocular antihistamines, ocular mast cell stabilizers, inhaled bronchodilators, inhaled corticosteroids, and inhaled anticholinergics are some of the ammunitions used to prevent and treat allergy and asthma symptoms that may occur in the Spring and other times as well. Allergy immunotherapy, (more commonly referred to as allergy shots), are very effective. They work in approximately 80-85% of the patients who take allergy shots. They take about 4-6 months however to work and the average person is on them for about 3-5 years.

If you are suffering from a prolonged “cold” and/or are not sure if your symptoms may be due to allergies and you would like to be seen by one of our board certified allergists at one of Black & Kletz Allergy’s 3 convenient locations in Washington, DC, McLean, VA (Tysons Corner, VA), or Manassas, VA, please call us to make an appointment. Alternatively, you can click Request an Appointment and we will get back to you within 24 hours by the next business day. We offer parking at each office location and we are Metro accessible at our Washington, DC and McLean, VA locations. We also offer a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. Black & Kletz Allergy provides a welcoming and thoughtful environment for you to get the state-of-the-art allergy, asthma, and immunology treatment that we have been providing the community for more than 5 decades.

Allergies and Asthma Due to Cockroaches

It is estimated that approximately 33% of people are allergic to cockroaches. Cockroaches are quite allergenic, which may attribute to the high number of individuals who are allergic to these nasty insects. There are over 3,500 species of cockroaches worldwide. Cockroaches have been around for more than 300 million years. They have adapted to living in all types of climates and are found all over the world. Cockroaches prefer to live in moist and warmer environments, so it quite common for them to live in bathrooms, basements, and kitchens. They are nocturnal, so they are rarely seen during the day.

Cockroaches also tend to be more common in the inner cities where between 30-60% of asthmatics living in an urban area are said to be allergic to cockroaches. This is particularly true of children living in inner cities where cockroaches are a major cause of asthma in these children. In fact, the percentage of cockroach sensitivity increases to between 55-80% in inner city children with asthma.

Most urban settings, including Washington, DC and Baltimore, MD, have quite a number of cockroaches living amongst them. It is estimated that more than 75% of homes and apartments in the inner city have cockroaches present. Even more appalling is that the number of cockroaches living in each home or apartment ranges from between 1,000 to over 300,000 insects. If you do the math, then for every cockroach you see in the home, there are approximately 800 cockroaches in that home that you don’t see.

When one talks about cockroaches causing allergies, it refers mostly to symptoms of allergic rhinitis (i.e., hay fever), allergic conjunctivitis (i.e., eye allergies), and asthma. The classic symptoms of allergic rhinitis may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, sinus headaches, and/or fatigue. Allergic conjunctivitis symptoms may include itchy eyes, watery eyes, puffy eyes, and/or redness of the eyes. Asthma symptoms are usually characterized by wheezing, chest tightness, coughing, and/or shortness of breath. There is a very strong correlation between chronic asthma and cockroach allergy. Other environmental allergens such as dust mites, mold, and pets can also cause year-round allergy symptoms and must also be evaluated when diagnosing an allergic or asthmatic patient for perennial symptoms. In addition to causing allergies and asthma, cockroaches can also carry and transmit various diseases such as gastroenteritis, cholera, dysentery, hepatitis, salmonella, typhoid fever, leprosy, parasites (i.e., roundworms, Giardia, Toxoplasmosis), polio, etc.

The causative agent of cockroach allergy is the cockroach allergens themselves. These allergens are found in the feces, saliva, and exoskeleton of the cockroach. The most common cockroach allergens are Bla g 1, Bla g 2, and Per a 1. Other cockroach allergens include Bla g 4, Bla g 5, Bla g 6, Bla g 7, Bla g 8, Bla g 9, Per a 2, Per a 3, Per a 4, Per a 5, Per a 6, Per a 7, Per a 8, Per a 9, and Per a 10. The latter are not as important in causing allergy symptoms to cockroach but they may play a role in some individuals.

The diagnosis of cockroach allergy begins with a comprehensive history and physical examination. Allergy skin testing or blood testing is often performed in order to confirm a cockroach allergy. In individuals with asthma, particularly inner city residents, a pulmonary function test is often performed. The management of cockroach allergies begins with preventing exposure to cockroaches. If there are cockroaches at home, getting a pest control company to help eliminate the cockroaches is your best start. In addition, there are some things that should be tried at home which may include: making sure to close up any holes in the walls or baseboards in order to decrease entry and exit paths for cockroaches; not leaving dirty dishes in the sink or on kitchen countertops; not bringing food into the bedrooms; keeping the garbage and food in closed containers; and/or making sure that there are no leaky pipes or faucets. For the treatment of cockroach allergy, there are a plethora of medications that may be used to help alleviate the unwanted symptoms. Oral antihistamines, oral decongestants, oral leukotriene antagonists, nasal corticosteroids, nasal antihistamines, nasal anticholinergics, ocular mast cell stabilizers and/or ocular antihistamines all can be used to decrease allergy symptoms caused by cockroach allergy. Asthma symptoms may be controlled with oral leukotriene antagonists, inhaled corticosteroids, inhaled long acting beta agonists, and/or inhaled short acting beta agonists. Oral corticosteroids may be needed in recalcitrant cases. Allergy shots (i.e., allergy injections, allergy immunotherapy, allergy desensitization, allergy hyposensitization) are a very effective means to treat cockroach allergy and are used in both adult and pediatric patients. They are efficacious in about 80-85% of the cases of allergic rhinitis, allergic conjunctivitis, and/or asthma. Most individuals are on allergy injections for approximately 3-5 years.

The board certified allergy specialists at Black & Kletz Allergy have been diagnosing and treating cockroach allergies and asthma for more than 5 decades. We treat both pediatric and adult patients. Black & Kletz Allergy has offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All 3 of our offices have on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. Our McLean office location offers a complementary shuttle that runs between our office and the Spring Hill metro station on the silver line. For an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from allergies and/or asthma symptoms, we are here to help lessen or hopefully end these undesirable symptoms that have been so bothersome, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy care in a relaxed, thoughtful, and professional environment.

Prevention of Food Allergies

LEAP and EAT Studies

A landmark study published in 2015 called “Learning Early About Peanut Allergy (LEAP),” revolutionized our understanding of the development of peanut allergy in children and transformed the guidance that pediatricians and allergists/immunologists give to parents about when to introduce peanut foods to children at high risk for food allergies.

Babies enrolled in the LEAP study were at high risk for developing peanut allergy because they already had severe eczema (i.e., atopic dermatitis), egg allergy, or both. Beginning at age 4-10 months, babies in the LEAP study were split into 2 groups and were followed for 4 years. One group avoided peanut foods, while the other group was given age-appropriate peanut foods several times a week. By age 5, the children who had begun eating peanut as infants were much less likely to be allergic to peanuts. Eating peanut foods early and regularly reduced the risk of peanut allergy by more than 80% compared to the group of children who avoided peanuts.

In a follow-up study called “Persistence of Oral Tolerance to Peanut (LEAP-On),” the results showed that peanut tolerance promoted by early introduction to peanut foods could be long-lasting. Children who ate peanuts from infancy to age 5 and then avoided peanuts from age 5 to age 6 were still 74% less likely to have peanut allergy than children who had consistently avoided peanut foods from infancy to age 6.

Does introducing allergenic foods early in life put a baby at a greater risk for food allergy?

A study published in 2016, called the “Enquiring About Tolerance (EAT)” study randomly assigned 1,300 breastfed infants to 1 of 2 treatment groups at age 3 months. One group was introduced to a sequence of 6 allergenic foods (i.e., milk, peanut, egg, sesame, fish and wheat), while the other group continued breastfeeding exclusively until age 6 months.

The EAT study revealed that rates of allergy to the 6 foods were not significantly different when the early introduction group and the exclusively breastfed group were compared at ages 1 and 3. This showed that early introduction of allergenic foods did not increase a baby’s risk for food allergy.

Does early introduction of egg products reduce the risk of developing egg allergy too?

In 2019, a new analysis of the EAT study data showed that early introduction of allergenic foods did protect against food allergies for some children at high risk. Children were considered at high risk if their blood tests showed specific IgE antibodies to the foods. They were considered sensitized. These specific IgE antibodies mediate allergic reactions.

Compared to exclusive breastfeeding, early food introduction reduced the likelihood that a baby would be sensitized to 1 or more of the 6 foods. It also made it less likely for the baby to develop an allergy to 1 or more of the 6 foods.
Early introduction of peanuts lowered the risk of developing peanut allergy in babies sensitized to peanuts. This finding is consistent with the LEAP study.
Early introduction of egg lowered the risk of developing egg allergy in babies sensitized to egg. Early introduction of foods including egg also provided protection against egg allergy in babies with moderate or severe eczema at age 3 months.
For babies who were not sensitized to any of the 6 foods at the beginning of the study, the risk of developing an allergy to 1 or more of the foods was similar in both the early introduction and exclusive breastfeeding groups.

These new findings from the EAT study indicate that early introduction of egg can provide protection against egg allergy for at least some children at high risk for developing egg allergy.

Guidance from American Academy of Allergy, Asthma & Immunology (AAAAI), American College of Allergy, Asthma & Immunology (ACAAI), and the Canadian Society for Allergy and Clinical Immunology:

To prevent peanut and/or egg allergy, both peanut and egg should be introduced around 6 months of life, but not before 4 months. Screening before introduction is not required. Other food allergens should be introduced around this time as well. Upon introducing complementary foods, infants should be fed a diverse diet, because this may help foster the prevention of a food allergy. Maternal exclusion of common allergens during pregnancy and/or lactation as a means to prevent food allergy is not recommended.

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

Christmas Tree Syndrome

Christmas tree syndrome is a relatively new term that is used to describe allergies to Christmas trees, whether they are real or artificial. The allergen can be the tree itself or it can be something that is on the surface of the tree.

Symptoms:

The symptoms of Christmas tree allergy are the same symptoms that an individual gets with classic cases of allergic rhinitis (i.e., hay fever) and/or allergic conjunctivitis (i.e., eye allergies). These symptoms may include sneezing, runny nose, nasal congestion, post-nasal drip, itchy nose, itchy throat, itchy eyes, watery eyes, redness of the eyes, sore throat, sinus congestion, sinus headaches, fatigue, and/or snoring. In individuals with asthma, Christmas trees may also exacerbate asthma symptoms such as chest tightness, wheezing, coughing, and/or shortness of breath.

Causes:

The causes of Christmas tree syndrome may include the pine pollen of the actual Christmas tree itself. It should be noted that pine pollen is fairly heavy and is not typically a major tree allergen when you compare it with other tree pollens such as maple, oak, elm, hickory, birch, etc. Despite it being less allergenic than other tree pollens, pine pollen can still however cause allergic rhinitis symptoms in sensitive individuals.

Natural Christmas trees are also known to carry more than 50 types of mold. Three-quarters of these molds are known to cause allergic rhinitis symptoms. It is also known that having a natural Christmas tree in one’s house will increase the amount of indoor mold since mold levels are higher in a room with a real Christmas tree as opposed to a room without a Christmas tree. Natural Christmas trees can also contain animal urine, pine tree sap, pesticides, insect droppings, and pollutants on them which may cause allergy-type symptoms in certain individuals. The scent of the terpenes found in pine tree sap can also trigger allergy symptoms, even though it is not technically an allergen, but rather an irritant.

Artificial Christmas trees may also have high levels of molds, but often have high levels of dust associated with them. Artificial Christmas trees also are often stored in dusty areas for prolonged periods of time. The dust that gathers on the surface of the trees may then play havoc with a sensitive person’s allergies. In addition, artificial Christmas trees may harbor insects, insect droppings, rodent urine, and rodent droppings which all may act as allergens that cause miserable allergy symptoms.

In addition to the Christmas tree itself, the decorations (e.g., ornaments, tinsel, garland, strings of lights, ribbon, pine cones, scented candles, poinsettias and other Christmas plants) may also possess allergens that may cause allergy symptoms.

Treatment:

The treatment of Christmas tree syndrome is to first remove the individual from the area in the house where the Christmas tree is located. Unfortunately, this is usually not possible because Christmas is a time to be with family members and most of the time that involves being in the room with the tree. If one is unable or unwilling to avoid exposure to the Christmas tree, one can use a variety of allergy medications to help alleviate the allergy symptoms. Oral antihistamines, oral decongestants, nasal corticosteroids, and/or nasal antihistamines are usually the initial treatment modalities in most allergic individuals. If other medications are needed, nasal anticholinergics and/or oral leukotriene antagonists can also be utilized.

Prevention:

Obviously, the prevention of Christmas tree exposure has the best outcome, but in the holiday spirit, the following things can help alleviate allergy symptoms in individuals who plan on putting up a Christmas tree. Some of the recommendations for minimizing allergy symptoms with Christmas trees may include cleaning the tree, keeping the tree outside, increase the ventilation of the room, minimize exposure to the tree, and/or use an alternative instead of a tree such as a Christmas “statue.” Christmas “candy cane,” etc.

The board certified allergy specialists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area and we have been providing allergy and asthma care to this area for more than 50 years whether it is Christmas or not. Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. All of our offices offer on-site parking. For further convenience, our Washington, DC and McLean, VA offices are Metro accessible. In addition, our McLean, VA office location offers a complementary shuttle that runs between this office and the Spring Hill metro station on the silver line. For an appointment, please call one of our offices. Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day. If you suffer from allergies or asthma, it is our mission to help alleviate your undesirable symptoms, so that you can enjoy a better quality of life. Black & Kletz Allergy is dedicated to providing the highest quality allergy and asthma care in an empathetic, relaxed, and professional environment.

Pollen Food Allergy Syndrome Update

Many patients who experience seasonal allergic rhinitis (i.e., hay fever) and allergic conjunctivitis (i.e., eye allergies) symptoms (e.g., sneezing, runny nose, nasal congestion, post-nasal drip, sinus congestion, itchy nose, itchy throat, sinus headaches, itchy eyes, watery eyes, redness of the eyes) caused by sensitivities to tree, grass, and weed pollens also may experience an itchy mouth and throat after eating certain fresh fruits and vegetables. As the symptoms are usually limited to the mouth and throat, this condition is known as “pollen food allergy syndrome” (PFAS). It is also known by the name “oral allergy syndrome” (OAS).

Most people with food pollen allergy syndrome have oral symptoms such as itching, burning, tingling, and occasionally swelling of the lips, mouth, tongue, and/or throat where the fresh fruit or vegetable touches the mouth. This represents a form of contact urticaria, since there is direct contact of the food to the mouth region. The symptoms usually only last a matter of seconds to a few minutes. The symptoms are also more likely to occur in the season that the cross-reactive pollens are also prevalent.

The oral symptoms occur only when a pollen-allergic individual is exposed to raw or fresh vegetables, fruits, and/or nuts. Food pollen allergy syndrome typically does not occur with cooked or baked fruits, vegetables, or processed fruits such as in applesauce as the cooking process inactivates or denatures the protein allergens in the foods. The exception to this rule is with celery and nuts where the oral allergy symptoms typically occur even if they have been cooked.

The cause for food pollen allergy syndrome is thought to be a cross-reactivity between the protein allergens in the pollen and the fresh fruits and/or vegetables. Fruit and vegetable proteins (i.e., allergens) share varying degrees of structural similarities with allergens found in pollens as well as other fruits and vegetables. This structural homology confuses the immune system and causes an allergic reaction to occur. The patient’s body “sees” the fruit or vegetable protein allergen as the pollen allergen and reacts to the food because it “thinks” it is the pollen. This homology or similarity between the food allergen and the pollen allergen is referred to as cross-reactivity.

Certain pollens are more likely to be cross-reactive with certain fruits, vegetables, and/or nuts. Below is a list of the cross-reactivity that may occur between common pollens and common raw or fresh fruits, vegetables, and/or nuts:

Alder pollen: almonds, apples, celery, cherries, hazelnuts, peaches, pears, parsley
Birch pollen: almonds, apples, apricots, avocados, bananas, carrots, celery, cherries, chicory, coriander, fennel, fig, hazelnuts, kiwi, nectarines, parsley, parsnips, peaches, pears, peppers, plums, potatoes, prunes, soy, strawberries, wheat, peanuts
Grass pollen: fig, melons, tomatoes, oranges
Mugwort pollen (i.e., celery-mugwort-spice-syndrome): carrots, celery, coriander, peppers, fennel, parsley, sunflower
Ragweed pollen: banana, cantaloupe, honeydew, watermelon, cucumber, zucchini, Echinacea, artichoke, dandelions, hibiscus tea, chamomile tea

Note: Any of the above pollens may cross-react with berries (e.g., strawberries, blueberries, raspberries), citrus (e.g., oranges, lemons), grapes, mango, fig, peanut, pineapple, pomegranates, and/or watermelon.

When a fruit or vegetable allergy develops in the absence of a pollen allergy, patients may be sensitized to nonspecific lipid transfer proteins (nsLTPs) or to gibberellin-regulated proteins (GRPs). In general, sensitization to these proteins is associated with higher rates of systemic reactions as well as higher rates of food-dependent, exercise-induced anaphylaxis. The allergens responsible for isolated food allergy are typically resistant to both heat and digestion and therefore have a greater potential to cause systemic symptoms.

There are also several syndromes that are associated with pollens and foods:

Celery-mugwort-birch-spice syndrome — The celery-mugwort-birch-spice syndrome is a potentially severe form of celery allergy seen in children and adults who are sensitized to both birch and mugwort pollens. Patients with this syndrome react to celeriac (i.e., root of the celery plant or celery tuber).
Mugwort-pollen food allergy syndrome — Patients sensitized to mugwort (Artemisia vulgaris) may develop a systemic food allergy (e.g., to mustard).
Latex-fruit syndrome — Approximately 30-50% of individuals who are allergic to natural rubber latex show an associated hypersensitivity to some plant-derived foods, especially fresh fruits. An increasing number of plant foods, such as avocado, banana, bell pepper, chestnut, kiwi, peach, tomato, and white potato, have been associated with this syndrome.

Diagnosis: The diagnosis is suspected when a comprehensive history is suggestive of pollen food allergy syndrome. Allergy tests such as prick skin testing, food elimination, and oral food challenges are helpful in establishing the diagnosis. Food prick skin testing with fresh foods is more reliable than commercial extract food prick skin testing because the process of making the extract can destroy the responsible protein allergen.

Treatment: The treatment of pollen food allergy syndrome involves avoiding exposure to the involved fresh or raw fruits, vegetables, and/or nuts to prevent the uncomfortable feeling in the mouth and throat, as well in order to reduce the risk of rare systemic symptoms. Taking antihistamines can minimize the severity of the symptoms however systemic reactions need treatment with epinephrine injections. Patients with a history of a systemic reaction should be prescribed a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick) and instructed on when and how to use it. It is important that the patient go immediately to the closest emergency room once a self-injectable epinephrine device is used.

Some studies have demonstrated that treating pollen allergies with allergy immunotherapy (i.e., allergy shots, allergy injections, allergy hyposensitization) can reduce the symptoms associated with cross-reacting fruits and vegetables that cause pollen food allergy syndrome.

The board certified allergy doctors at Black & Kletz Allergy will eagerly respond to your needs for further information and services in dealing with food allergies, pollen food allergy syndrome, and other allergic and immunologic disorders. The allergists at Black & Kletz Allergy have 3 convenient locations in the Washington, DC, Northern Virginia, and Maryland metropolitan area. Our offices are located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We offer on-site parking at all of our offices and our Washington, DC and McLean, VA offices are Metro accessible. There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line. To make an appointment, please call our office or alternatively, you can click Request an Appointment and we will respond to your inquiry within 24 hours by the next business day. Black & Kletz Allergy treats both adults and children and we strive to provide the best and most current diagnostic and treatment modalities in the Washington, DC metro area, as we have done for more than 5 decades.

Corn Allergy and Corn Intolerance

Corn (i.e., maize) is a popular staple food worldwide, providing essential nutrients such as vitamins, minerals, and fiber. Corn is also a common component of processed foods. Despite its nutritional value and popularity, for those individuals with corn allergies or corn intolerance, consuming corn or corn-derived products may lead to adverse health effects.

Although corn allergies and intolerance are relatively uncommon compared to other food allergies and intolerances, they can still cause significant discomfort and health issues for affected individuals.
Corn allergies are caused by an overreaction of the immune system to proteins found in corn whereas corn intolerance typically results from the body’s inability to digest or process corn.

Corn Allergy:

There may be a genetic predisposition to developing a corn allergy, as it is more common in individuals with a family history of allergies or other allergic conditions, such as asthma or eczema (i.e., atopic dermatitis). Corn allergy is not a very common food allergy. The prevalence of corn allergy is approximately 2% in whites, 7% in Hispanics, and 15% in African Americans. Corn allergy occurs when the immune system mistakenly identifies corn proteins as harmful substances. As a result, an allergic reaction ensues against the corn protein. In this allergic reaction, the body produces immunoglobulin E (IgE) antibodies which trigger the release of chemical mediators such as histamine, leukotrienes, prostaglandins, as well as other inflammatory chemicals. In doing so as a mechanism to “kill” or “get rid of” the allergen (e.g., corn protein), the individual experiences classic allergy symptoms such as itching (i.e., pruritus), hives (i.e., urticaria), swelling (i.e., angioedema), gastrointestinal symptoms, wheezing, shortness of breath, or anaphylaxis.

Zein is the major storage protein found in corn. It makes up about 45% of the protein in corn. Zein is used as a coating for nuts, pills, candy, fruit, as well as other encapsulated foods and medications. In addition to zein, lipid transfer protein and profilin are two other proteins that are found in corn. These 2 proteins are primarily responsible for most of the corn allergy that occurs. Allergies to the heat-stable lipid transfer protein in corn may cause severe allergic reactions whereas an allergy to the heat-sensitive profilin protein usually only cause mild to moderate reactions.

Symptoms:

Mild to moderate corn allergy symptoms may include sneezing, itchy mouth, itchy throat, runny nose, nasal congestion, post-nasal drip, generalized itching, hives, and/or gastrointestinal issues such as nausea, vomiting, and/or diarrhea.

In rare instances, corn allergy may lead to anaphylaxis, a severe and potentially life-threatening allergic reaction. The symptoms of anaphylaxis may include hives, swelling of the throat or tongue, wheezing, shortness of breath, rapid or weak pulse, and/or a sudden drop in blood pressure.

Diagnosis:

The diagnosis of corn allergy requires a thorough history of the timeline of consumption of the corn-containing food(s) and the symptoms experienced. The diagnosis can be confirmed by identification of corn specific IgE antibodies either by skin prick testing or by blood testing. The gold standard for establishing the diagnosis of corn or any other food allergy however is an oral food challenge.

Corn allergy may be associated with cross-reactivity to other food allergens such as certain grains, legumes, and seeds. A high degree of cross-reactivity has been demonstrated among the lipid transfer proteins of corn (maize), peach, apple, apricot, walnut, hazelnut, peanut, rice, sunflower seeds, and French beans. This cross-reactivity means that individuals with a corn allergy may also experience allergic reactions to other foods containing similar proteins.

Occupational exposure to maize, maize dust, or maize flour may result in occupational asthma or rhinitis, in particular in mill workers, bakery workers, and those working in the animal feed industry. Allergic reactions have also been reported to cornstarch powder when used as a glove lubricant. Symptoms include hives, swelling episodes, sneezing, runny nose, nasal congestion, post-nasal drip, itchy eyes, watery eyes, redness of the eyes, asthma, and/or intermittent episodes of shortness of breath.

Corn has been implicated as one of the foods that can cause eosinophilic esophagitis, a disorder with symptoms suggestive of gastroesophageal reflux disease (GERD) but unresponsive to conventional anti-reflux therapies.

Treatment:

The treatment of corn allergy usually includes the use of antihistamines. Antihistamines can relieve the mild symptoms of allergic reactions such as itching and rashes. Severe reactions such as anaphylaxis usually require epinephrine injections either with a syringe and a needle or with a self-injectable epinephrine device (e.g., EpiPen, Auvi-Q, Adrenaclick). It should be noted that if an individual uses a self-injectable epinephrine device, they must go immediately to the closest emergency room.

Prevention:

The avoidance of foods containing corn products is the only definitive preventive measure. It is essential to read food labels carefully, as corn-derived ingredients can be found in various foods under different names, such as cornstarch, corn syrup, dextrin, and maltodextrin. It is essential to be vigilant about identifying hidden sources of corn and choosing alternative products when necessary. Corn may be present in salad dressings, sauces, processed meats, and in certain medications and supplements.

Corn Intolerance:

Certain enzymes such as amylase are necessary to break down complex carbohydrates into simple digestible sugars. The deficiency of these enzymes can result in bothersome gastrointestinal symptoms such as abdominal bloating, cramping, abdominal pain, and diarrhea after consuming corn products.

Sensitivity to specific corn components, such as cornstarch or corn syrup, may also contribute to corn intolerance. Though less common, intolerance can also result in skin manifestations such as rashes and itching, as well as respiratory symptoms such as cough, chest tightness, wheezing, and/or shortness of breath.

Corn is a low FODMAP food. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols. Foods high in FODMAPs may cause symptoms of food intolerance, thus affecting the gastrointestinal system. These symptoms of intolerance however can be mistaken for a true food allergy. Note that even though corn is a low FODMAP food, corn syrup, on the other hand is a high fructose food and thus considered a high FODMAP food.

Corn, like other grains, contains a moderate amount of lectins. Lectins are another cause of food intolerance. Cooking foods with lectins makes them more digestible and can reduce the symptoms of food intolerance however.

Corn allergy has been associated with a condition called “latex food syndrome.” The syndrome occurs when an individual who has a latex eats a food that has proteins in it that are similar to the proteins found in latex. The rubber tree plant Hevea brasiliensis which is involved in latex allergy, has an allergen called Hev b 11 which is a chitinase protein. Many plant and animal tissues contain chitinase proteins which are allergenic. Corn, kiwi, chestnut, mango, banana, avocado, pomegranate, and dates all contain chitinase proteins. Those that are sensitized to latex may have allergic reactions from foods containing similarly shaped proteins. Approximately 30% to 50% of individuals with latex allergies have a cross-reaction to foods with these proteins. The symptoms are primarily oral symptoms (e.g., itchy mouth, lips, tongue and throat) and are often referred to as oral allergy syndrome or pollen food allergy syndrome. Oral allergy syndrome mostly affects people who already suffer from pollen allergies and seasonal allergic rhinitis.

Prognosis:

Healthcare professionals, patients, and caregivers all play a vital role in the successful management of corn intolerance and allergies. Working together to identify triggers, develop individualized management plans, and provide ongoing support can help ensure that individuals with corn allergies or intolerance can live healthy and fulfilling lives.

If you suffer from a corn allergy or other food allergy or intolerance of any kind, the board certified allergists at Black & Kletz Allergy have the expertise in order to diagnose and manage this condition. We treat both pediatric and adult patients and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. We have on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible. Please either call us for an appointment or you may alternatively 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 treating allergy, asthma, and immunology patients in the Washington, DC metropolitan area for more than 5 decades and we strive to provide state-of-the-art allergy care in a professional and amiable setting.

Allergies and Sleep Apnea Update

Snoring is not an uncommon symptom in patients with allergic rhinitis (i.e., hay fever). Snoring is the harsh sound that arises when air flows past the relaxed tissues in the throat. The actual snoring sound is a result of the vibration of the throat’s tissues as one breathes. Mild intermittent snoring is quite common and occurs in almost everyone. Chronic moderate or severe snoring however is not normal and may indicate a serious health malady. It may also point to an underlying health condition such as sleep apnea, allergic rhinitis, nasal polyps, obesity, enlarged tonsils, etc.

Sleep apnea is a condition in which one’s breathing is continually interrupted. The result is the inability to get enough deep sleep that is essential to revitalize the body. The characteristic symptoms of this condition include extreme daytime somnolence which often results in falling asleep at inappropriate times. Sleep apnea should not be taken lightly as it can be very serious and is a potentially fatal disorder. In addition to falling asleep and daytime sleepiness, other symptoms may include snoring (as mentioned above), fatigue, depression, diminished productivity at work and/or school, decreased memory, decreased quality of life, and a reduced ability to learn. As mentioned above, allergic rhinitis (i.e., hay fever) has also been linked to many of the same symptoms. Allergic rhinitis in combination with sleep apnea can have harmful effects including heart disease, stroke, sexual dysfunction, and an increased risk for motor vehicle accidents. As a result, sleep apnea should be taken seriously. Although it is estimated that roughly 25 million adults in the U.S. have sleep apnea. The actual numbers are probably much higher since cases are underdiagnosed due to a variety of reasons. In addition, many individuals with sleep apnea are simply unaware that they have the condition.

There are 2 types of sleep apnea, “obstructive sleep apnea” and “central sleep apnea.” In obstructive sleep apnea, the breathing or air flow is blocked or “obstructed.” The obstruction is often caused by the tongue sliding back in the throat. In addition, the relaxed airway that occurs during sleep changes shape to a more oval shape. This change in shape of the airway contributes to the decrease in air that reaches the lungs. In essence, the muscles of the throat relax and fail to hold the airway open during sleep. As a result, oxygen levels are decreased in the tissues. In central sleep apnea, the normal unconscious breathing basically stops, usually due to the brain not sending the normal signals to the muscles that control breathing. Central sleep apnea is much less common than the obstructive type of apnea and not associated with allergies. For the purposes of this blog article, only obstructive sleep apnea is discussed.

The severity of the sleep apnea can be put into 3 categories: mild, moderate, and severe. The severity is based on the number of episodes or events of apnea that occur per hour of sleep. An episode or event is described as a complete stoppage of breathing for at least 10 seconds or shallow breaths for at least 10 seconds. Sleep apnea is considered “mild” when there are 5-14 episodes of apnea or hypopnea (i.e., shallow breathing) per hour. It is deemed “moderate” when there are 15-29 episodes of apnea or hypopnea per hour. It is called “severe” when there are 30 or more episodes of apnea or hypopnea per hour.

The diagnosis of sleep apnea is best done with a sleep study. Historically, patients were asked to come to a sleep center for an overnight sleep study. During the sleep study the individual’s blood pressure, heart rate, respiratory rate, oxygenation level, and brain electrical activity is monitored throughout the night. More recently, the sleep study is often done in the patient’s home with some of these measures closely monitored and recorded. In addition allergy skin testing or blood testing may be performed in individuals exhibiting allergic rhinitis symptoms. Some of these symptoms may include sneezing, itchy nose, runny nose, nasal congestion, post-nasal drip, snoring, sinus pressure, sinus headaches, fatigue, itchy throat, itchy eyes, watery eyes, and/or redness of the eyes.

The most efficacious management of sleep apnea is the use of CPAP (continuous positive airway pressure) while sleeping. CPAP machines are used in order to deliver a continuous flow of pressure which as a result forces open the obstruction in the airway. The patient has 3 options how to receive the continuous airflow delivered by the CPAP machine which includes a full face mask, a nasal mask, or nasal pillows or prongs. The full face mask is the most cumbersome whereas the nasal pillows or prongs are the least awkward. The choice is completely up to the patient and many individuals try all 3 until they find the best match for themselves. It should be pointed out that the main obstacle in the treatment of sleep apnea is compliance, as more than half of patients do not use CPAP when prescribed, mostly due to it being uncomfortable and annoying.

The use of dental or mouth devices are controversial but may help lessen symptoms in patients with mild obstructive sleep apnea. Surgery can also be performed in order to improve obstructive sleep apnea. The “Inspire Sleep Apnea Innovation” is a form of upper airway stimulation (UAS). It is a surgical procedure in which a monitoring device is implanted into one’s chest and a neurostimulator device is implanted below one’s chin in order to monitor one’s breathing and send a gentle pulse to the nerve that controls tongue motor function, moving it forward and out of the way so one can breathe properly. This treatment received FDA approval in 2014. Other surgical procedures are somewhat controversial in regards to their efficacy. One of these is a uvulopalatopharyngoplasty which is one of the most common surgical procedures for treating obstructive sleep apnea, although as mentioned above, not necessarily the most effective. It is performed to remove excess tissue in the throat such as the uvula, adenoids, tonsils, and parts of the soft palate.

Black & Kletz Allergy has 3 convenient locations with on-site parking located in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA. The Washington, DC and McLean, VA offices are Metro accessible and we offer a free shuttle that runs between the McLean, VA office and the Spring Hill metro station on the silver line. The board certified allergy doctors at Black & Kletz Allergy are extremely knowledgeable regarding the diagnosis and treatment of snoring and sleep apnea. In our practice we also treat patients with environmental allergies (i.e., allergic rhinitis or hay fever), eye allergies (allergic conjunctivitis), asthma, eczema (i.e., atopic dermatitis), hives (i.e., urticaria), contact dermatitis, medication allergies, generalized itching (i.e., pruritus), swelling episodes (i.e., angioedema), insect sting allergies, food allergies, eosinophilic esophagitis, Mast cell disorders, and immune disorders. To schedule an appointment, please call any of our offices or you may click Request an Appointment and we will respond within 24 hours by the next business day. We have been serving the greater Washington, DC metropolitan region for more than 50 years and we look forward to providing you with exceptional allergy care in a welcoming and professional environment.