ON STAFF CLEVELAND CLINIC INDIAN RIVER HOSPITAL STAFF

If you have allergic rhinitis, your immune system mistakenly identifies a typically harmless substance as an intruder. This substance is called an allergen. The immune system responds to the allergen by releasing histamine and chemical mediators that typically cause symptoms in the nose, throat, eyes, ears, skin and roof of the mouth.

Seasonal allergic rhinitis (hay fever) is most often caused by pollen carried in the air during different times of the year in different parts of the country.

Allergic rhinitis can also be triggered by common indoor allergens such as the pets, dust, mold and other particles. This is 'perennial' allergic rhinitis, as symptoms typically occur year-round.

In addition to allergen triggers, symptoms may also occur from irritants such as smoke and strong odors, or to changes in the temperature and humidity of the air. This happens because allergic rhinitis causes inflammation in the nasal lining, which increases sensitivity to inhalants.

Many people with allergic rhinitis are prone to conjunctivitis (eye allergy). In addition, allergic rhinitis can make symptoms of asthma worse for people who suffer from both conditions.

Allergic rhinitis symptoms include:

• Itching in the nose, mouth, throat, eyes
• Sneezing
• Stuffy nose (congestion)
• Runny nose
• Tearing eyes
• Circles under the eyes
• 
  

Hay fever symptoms tend to be in spring and fall. Perennial allergic rhinitis occurs year-long.

An allergy doctor has specialized training and experience to diagnose which allergens  trigger your illness, or to determine if your symptoms are non-allergic. Your allergist will take a thorough health history often followed by allergy testing. 

Pollen are microscopic seeds which can fertilize plants. Pollen from flowers  usually do not trigger allergies. These rely on insects, not air, to move the pollen. Allergenic plants produce lightweight pollen that are easily carried by wind. These pollen cause allergy symptoms.

Each plant has a period of pollination that does not vary much from year to year. However, the weather can affect the amount of pollen in the air at any time. Seasonal allergic rhinitis is often caused by tree pollen in the early spring. During the late spring and early summer, grass pollen often cause symptoms. Late summer and fall hay fever is caused by weed pollen. In warmer places, pollination can be year-round.

Molds are simply fungi, related to mushrooms but they do not have stems, roots or even leaves. Molds can be found everywhere, including soil, plants and rotting wood. Their spores float in the air, much like pollen.  They can be found year-round in Vero Beach and Port Saint Lucie.

EPIPEN can be a life-saving tool, but it does not always work. Sometimes the dose is too low, sometimes it does not work quickly enough, and sometimes other medications are also needed. Another approach, venom-specific immunotherapy, is highly effective and well tolerated.  

Yellow jackets form nests that resemble paper-maché material and are usually underground, but sometimes be found in the walls of frame buildings, cracks in masonry or woodpiles.

Honeybees are not aggressive and in general only sting when provoked. However, Africanized honeybees ( "killer bees") are more aggressive and sometimes sting in swarms. Domesticated honeybees live in man-made hives, while wild honeybees live in colonies or "honeycombs" often in trees or abandoned buildings.

Paper wasps form nests are that look like a circular comb of cells and opens downward. The nests can be located under eaves, behind shutters, or in discarded areas.

Hornets nests are gray or brown in color, can be football-shaped and are usually elevated above ground on branches, in shrubbery.

Fire ants construct large mounds of dirt in the ground and are found on golf courses in Port Saint Lucie and throughout Vero Beach.

Venom immunotherapy. Remember that epinephrine is a rescue medication only, and you must still have someone take you to an emergency room immediately if you are stung. Those with severe allergies may want to consider wearing a bracelet or necklace that identifies the wearer as having severe allergies, or they might be able to receive FDA-approved allergy injections to prevent future reactions.

Read an article published by Dr Michael Wein on severe venom allergy - CLICK.

Food allergies begin in the immune system. For example, if you have food allergy to peanut, the immune system identifies a protein found in peanuts as an allergen. The immune system reacts by producing IgE (antibodies of the type called Immunoglobulin E). These antibodies attach to specific cells (called mast cells and basophils). If someone comes in contact with the allergen, the cells release a wide variety of proteins and chemicals including histamine, which cause food allergy symptoms such as itching, hives, swelling, diarrhea, wheezing and a potentially life-threatening reaction called anaphylaxis. Unless immediate treatment is given—an injection of epinephrine and expert care—anaphylaxis can in rare cases be fatal.

It is important to note a difference between food allergy and intolerance. Food allergy involves the immune system while food intolerance, such as lactose intolerance, does not. Food intolerance typically involves the GI tract, causing symptoms like abdominal pain, nausea, vomiting and diarrhea. There is yet another type of reaction, caused by immune reaction, called "celiac", which can also lead to food reactions. It can in fact required advanced testing to determine the cause.

IN the USA, the most common food allergens are cow milk, egg, peanut, wheat, soy, fish, shellfish and tree nut. Sometimes an allergy to one member of a food family may result in the person being allergic to other members of the same group. This is known as cross-reactivity.

Most food allergens can cause allergic reactions even after they are cooked or have undergone digestion in the intestines, but in some cases cooking destroys the allergen.

IN genreal symptoms of food allergy occur within 2 hour, but within the past few years a new type of food allergy has been found by allergists and published in the New England Journal of Medicine, it is called alpha gal, with symptoms that may be delayed.

An allergy doctor, often referred to as an allergist, has specialized training and expertise to determine if your symptoms are caused by a food allergy or due to other food-related disorders such as food protein-induced enterocolitis syndrome (FPIES) or eosinophilic esophagitis (EoE).

Allergy skin tests may determine which foods, if any, trigger your allergic symptoms. In skin testing, a small amount of extract made from the food is placed on the back or arm. If a raised bump or small hive develops within 20 minutes, it indicates a possible allergy. If it does not develop, the test is negative. It is uncommon for someone with a negative skin test to have an IgE-mediated food allergy.
 

When the immune system is either absent or not functioning properly, it can result in an immune deficiency disease. When the cause of this deficiency is hereditary or genetic, it is called a primary immunodeficiency disease (PIDD). There are over 300 different kinds of PIDD.

The immune system includes white blood cells. These cells start in the bone marrow and move through the bloods and lymph nodes to defend against bacteria and fungi. Antibodies are another part of the system, they are proteins that are made in response to infection and help fight infections. Complement is yet another part of the system, a blood protein that plays a protective role in the immune system.  

In the most common types of PIDDs, cells or proteins are missing or do not function. This results in repeated infections, which might affect the skin, sinus, lungs, ears, the brain or stomach.  Sometimes an immune deficiency results in an "autoimmune" disorders.

Nasal Polyps 

Chronic rhino-sinusitis is a common medical condition. It results in inflammation of the nose and sinus and sometimes even nasal polyps.  Nasal polyps are massive accumulations of eosinophils that may block air flow. Nasal polyps can be on one or both sides of the nose, and might be mistaken for malignant nasal or sinus tumors.
 

The exact cause might be related to elevated allergic type of cells known as eosinophils  (read more about Dr Wein’s research on eosinophils). Infection may also play a role. When they occur in children, polyps might be a sign of cystic fibrosis.

Symptoms
Symptoms include nasal drainage, nasal congestion, facial pressure or pain, and a decrease in sense of smell (which also occurs with covid-19). Of all the symptoms, nasal congestion and loss of smell tend to be the most troublesome. Polyps tend to recur, even after they are removed surgically, so surgery is usually a last resort.

Diagnosis
The diagnosis of nasal polyps is based on a combination of history, physical examination and often a sinus CT scan. The history of nasal congestion and loss of smell points to nasal polyps. Asthma occurs in many patients with polyps, and worsening nasal symptoms or with use of aspirin or ibuprofen.  Allergic fungal rhinosinusitis is related to mold, and seems to return even after sinus surgery.
 

Management and Treatment
Medical treatment of includes both topical nasal steroid sprays, nasal saline rinses, and sometimes monoclonal antibodies. Steroid sprays help reduce polyp size and improve symptoms. Short courses of oral steroids can also help shrink nasal polyps and have shown to improve symptoms including sense of smell, however they should be used cautiously given the risk of steroid side effects. Sinus surgery to remove polyps is an option if nasal polyps are bothersome despite oral and/or corticosteroid sprays. Unfortunately, polyps often recur despite surgery and long-term treatment with nasal steroids or large volume steroids are often necessary.
 

A biologic medicine called dupilumab, which has been approved to treat moderate to severe asthma, has also gained approval to treat polyps. Dupilumab is given as an injection every other week and has been shown to reduce the need for surgery and treatment with oral steroids. Future therapy is also under investigation.

 

Allergic Reactions to Drugs
Allergy symptoms - a reaction in the immune system. One type of immune reaction is due to antibodies called Immunoglobulin E (IgE). These antibodies trigger cells that release chemicals, which causes symptoms in the nose, lungs, throat, stomach and skin. This usually rapidly.

The most common immune response to a drug is not due to IGE, but rather due to the expansion of T cells, a type of white blood cells. These T cells orchestrate a delayed immune response that can affects the skin, causing itchy rashes, and often occurs days to weeks after exposure to the drug.
 

The most severe form of immediate allergic reactions is anaphylaxis.  Symptoms of anaphylaxis include hives, facial or throat swelling, wheezing, light-headedness, vomiting and even shock.
 

Antibiotics and foods are a common trigger of anaphylaxis, but other triggers have also been shown to induce anaphylaxis. Other severe reactions, which are not anaphylaxis, include Stevens Johnson Syndrome, Toxic Epidermal Necrolysis, and Acute generalised exanthematous pustulosis,
 

You should seek medical help immediately if you experience any of these. Many medications can cause these severe delayed reactions including antibiotics, medications for epilepsy (seizures), depression and gout.
 

If you take angiotensin converting enzyme (ACE) inhibitors for high blood pressure, you may develop a cough or facial and tongue swelling. This can be related to increase in bradykinin levels. 

Another type of drug reaction is serum sickness. This is a Type III reaction. Immune complexes can deposit in your body, often in your joints or kidneys but also in the skin. Sometimes this can also involve the complement components.  Complement is a system  of plasma proteins that can be activated directly by bacteria or sometimes by a drug or antibody, leading to a cascade of reactions. 

In addition, some people are sensitive to aspirin, ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs). One type of aspirin or NSAID sensitivity may cause a stuffy nose, wheezing and difficulty breathing. This is most common in adults with asthma and in people with nasal polyps.

Non-Allergic Reactions
Non-allergic reactions are much more common than drug allergic reactions. These reactions are usually based on the properties of the drugs involved. Symptoms of non-allergic drug reactions vary, depending on the type of medication. People being treated with chemotherapy often suffer from vomiting and hair loss. Certain antibiotics irritate the intestines, which can cause stomach cramps and diarrhea.