Scientists “Speak” on Mold Allergy

Background

  • Allergic bronchopulmonary aspergillosis is a pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus, and rarely other Aspergillus species, and is characterized by chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis.
  • An ABPA-like syndrome called allergic bronchopulmonary mycosis is indistinguishable from ABPA but is caused by other fungi.
  • The condition occurs almost exclusively in patients with cystic fibrosis (CF) or asthma.
  • The global prevalence of allergic bronchopulmonary aspergillosis is reported to be 2.5% (range 0.7%-3.5%) among adults with asthma and reported to be 2%-15% in patients with cystic fibrosis.

Evaluation

  • Suspect allergic bronchopulmonary aspergillosis (ABPA) in patients with asthma or cystic fibrosis who have symptoms consistent with ABPA, such as:
    • difficult-to-control asthma
    • new or worsening cough
    • dyspnea
    • increased sputum production
    • expectoration of brown-black mucus plugs
    • wheezing
    • hemoptysis
  • ABPA may also be suspected in patients with computed tomography (CT) findings of bronchiectasis, especially central bronchiectasis.
  • Multiple sets of diagnostic criteria exist, all of which include a combination of clinical signs, imaging findings, and serologic features.
    • Rosenberg-Patterson diagnostic criteria for patients without cystic fibrosis (most commonly used):
      • major criteria for diagnosis (at least 6 required for diagnosis):
        • asthma
        • transient pulmonary opacities on imaging (fleeting shadows)
        • positive skin test for Aspergillus (type 1 immediate hypersensitivity)
        • peripheral blood eosinophilia (> 1,000 cells/mcL)
        • precipitating antibodies (immunoglobulin [Ig] G) against Aspergillus fumigatus in serum
        • elevated total IgE > 1,000 units/mL
        • central/peripheral bronchiectasis with normal tapering of distal bronchi
        • elevated A. fumigatus-specific IgG and IgE
      • minor criteria:
        • Aspergillus in sputum
        • brownish black mucus plugs in expectorate
        • delayed type III skin reaction to Aspergillus
    • Cystic Fibrosis Foundation diagnostic criteria for patients with cystic fibrosis:
      • classic case (all criteria required):
        • acute or subacute clinical deterioration (cough, wheeze, exercise intolerance, increased sputum, decrease in pulmonary function, exercise-induced asthma) not attributable to other cause
        • serum total IgE > 1,000 units/mL (2,400 ng/mL) in patient not on corticosteroids
        • immediate skin reaction to Aspergillus (wheal > 3 mm diameter with erythema in patient not on antihistamines) or positive serum IgE antibody to A. fumigatus
        • precipitating antibodies to A. fumigatus or serum IgG antibody to A. fumigatus
        • recent or new infiltrates or mucus plugging on chest x-ray or bronchiectasis on chest computed tomography (CT) that does not clear with antibiotics or chest physiotherapy
      • minimal diagnostic criteria:
        • acute or subacute clinical deterioration not attributable to other cause
        • serum total IgE > 500 units/mL (1,200 ng/mL) (if disease suspected and serum total IgE is 200-500 units/mL, repeat testing in 1-3 months)
        • immediate skin reaction to Aspergillus or positive serum IgE antibody to A. fumigatus
        • 1 of following:
          • precipitins to A. fumigatus or IgE antibody to A. fumigatus
          • recent or new infiltrates or mucus plugging on chest x-ray or bronchiectasis on chest CT that does not clear with antibiotics and standard chest physiotherapy
      • diagnosis of ABPA in cystic fibrosis should not be based in serology and skin tests only(2)

Management

  • Treatment goals include:
    • control of symptoms of asthma and cystic fibrosis
    • prevention or treatment of pulmonary exacerbations of allergic bronchopulmonary aspergillosis (ABPA)
    • reducing or remitting pulmonary inflammation
    • avoiding progression to end-stage fibrotic or cavitary disease
  • No large randomized trials have evaluated efficacy of various treatment options as of September 20, 2017.
  • Refer patients with suspected or known ABPA to a pulmonologist or an allergist-immunologist.
  • Systemic corticosteroids are considered the cornerstone of therapy for ABPA.
    • In patients with asthma:
      • typical initial therapy is prednisone 0.5 mg/kg/day (or equivalent) with tapering dose as symptoms improve
      • for patients with mild exacerbation – inhaled corticosteroids and bronchodilators may help control symptoms
      • for patients with acute exacerbation – prednisone 0.5-1 mg/kg/day for 1-2 weeks, then 0.5 mg/kg every other day for 6-12 weeks following remission, then tapering dose to preexacerbation dose
      • for patients with refractory disease with multiple asthmatic exacerbations – chronic corticosteroid therapy suggested, usually > 7.5 mg/day
      • dosing may be increased based on findings from routine monitoring of serum immunoglobulin E (IgE) levels, pulmonary function tests, and chest imaging, such as:
        • significant increase of IgE levels (such as doubling of baseline IgE level)
        • imaging evidence of infiltrates, mucoid impaction, fibrosis, worsening bronchiectasis, or worsening physiology
    • In patients with cystic fibrosis:
      • oral corticosteroids indicated for all patients except those with corticosteroid toxicity
      • typical initial dose prednisone (or equivalent) is 0.5-2 mg/kg/day orally to maximum 60 mg/day for 1-2 weeks, tapering to 0.5-2 mg/day every other day for 1-2 weeks with attempt to taper completely within 2-3 months
      • in patients with relapse, increase corticosteroid dose, add itraconazole, and taper corticosteroids when clinical status improves
  • Inhaled corticosteroids and methylprednisolone IV pulses may be used in some situations.
  • Consider antifungal agents in adults with severe, poorly controlled asthma and ABPA (Weak recommendation).
  • Combination antifungal/corticosteroid (nebulized amphotericin B and nebulized budesonide) may reduce the incidence of exacerbations.
  • Omalizumab may reduce exacerbations but may not improve or affect lung function or quality of life.
  • For refractory cases, consider evaluating the patient’s environment for significant mold exposure that can be modified (Weak recommendation).
  • Consider adjunct leukotriene antagonists for some patients (Weak recommendation).
  • Follow-up could include imaging at 4-8 weeks and total serum IgE monitoring.
 2017 Aug;13(8):823-835. doi: 10.1080/1744666X.2017.1324298. Epub 2017 May 17.

Mold allergy: is it real and what do we do about it?

 

Abstract

fungi produce substances that contain pathogen-associated molecular patterns (pamps) and damage-associated molecular patterns (damps) which bind to pattern recognition receptors, stimulating innate immune responses in humans. they also produce allergens that induce production of specific ige. Areas covered: In this review we cover both innate and adaptive immune responses to fungi. Some fungal products can activate both innate and adaptive responses and in doing so, cause an intense and complex health effects. Methods of testing for fungal allergy and evidence for clinical treatment including environmental control are also discussed. In addition, we describe controversial issues including the role of Stachybotrys and mycotoxins in adverse health effects. Expert commentary: Concerns about long-term exposure to fungi have led some patients, attorneys and fungus advocates to promote fears about a condition that has been termed toxic mold syndrome. This syndrome is associated with vague symptoms and is believed to be due to exposure to mycotoxins, though this connection has not been proven. Ultimately, more precise methods are needed to measure both fungal exposure and the resulting health effects. Once that such methods become available, much of the speculation will be replaced by knowledge.

Lips Like Strawberry Wine…

 

Sometimes even I get surprised by a clinical problem that may not be due to allergy. Every 2-3 months, a patient will come in to the office wondering what has caused the redness, swelling, and cracking of their lips, a condition called chelitis. Of course we many times think this is due to #food allergy, but think again. I wish it were as easy as food allergy. 

Yes, it’s true that foods go past your lips in order to be swallowed, but that may not have anything to do with food allergy or fixing your problem. 

Let’s get it on with those not so strawberry lips….

Background

Evaluation

  • Patients with irritant or allergic cheilitis may present with dryness, scaliness and/or fissuring, with or without erythema or edema of the vermillion border.
    • Ask about common allergens, such as lipsticks, cosmetics, nail polishes, and oral hygiene products; and common irritants, such as wind or cold weather exposure, irritative topicals (lip cosmetics, antiseptics), repeated lip-licking behaviors, and musical instrument contact.
    • For allergic contact cheilitis, consider patch testing if the culprit allergen is not identified by history.
  • Angular cheilitis (also called perleche) may occur in young children or in adults with dentures or dental appliances. Erythema, scaling, fissuring, bleeding, or ulceration is seen at the angle (corner) of the lip, and may be unilateral or bilateral.
  • Actinic cheilitis (also called solar cheilosis) typically presents in older adults (aged > 40 years), more commonly in fair-skinned individuals, and is more common in men. Actinic cheilitis may be seen as dryness, scaliness, color variation on lip, atrophy, leukoplakia, erythema, solitary papule or nodule, and/or with blurring of the vermilion border. Consider biopsy to rule out cutaneous squamous cell carcinoma.
  • Consider other differential diagnoses of lip lesions, such as cutaneous squamous cell carcinoma, basal cell carcinoma, melanoma, salivary gland tumors and metastatic tumors of the lip.

Management

  • Management for any identified infection should follow usual, advised treatment.
  • Management for any identified generalized or systemic causes of cheilitis, such as atopic dermatitis or lichen planus should follow usual, advised treatment.
  • For allergic or irritant cheilitis, advise patients to avoid the culprit agent or exposure. Consider short-term topical steroids for symptoms of pain or pruritus.
  • Management of actinic cheilitis may depend on the type of lesion.
    • For lesions with suspicious features of cutaneous squamous cell carcinoma, obtain biopsy.
    • For well-circumscribed nodules or papules, consider surgical excision.
    • For larger focal lesions, prolonged ulceration, and areas of atrophy, consider topical 5-fluorouracil or imiquimod, or ablation with cryotherapy or electrosurgery.
    • For diffuse disease, particularly if the vermilion border is involved, consider topical 5-fluorouracil or imiquimod, photodynamic therapy, vermilionectomy, or laser treatment.
  • Management of angular cheilitis (perleche) depends on the cause.
    • For idiopathic angular cheilitis, consider application of an emollient barrier such as petroleum jelly.
    • Advise correction or elimination of any sources of irritation, such as ill-fitting dentures.
    • For Staphylococcal infection, use topical mupirocin or fusidic acid.
    • For Candidal infection, use a topical antifungal, such as ketoconazole 2% cream.
    • Replete nutritional deficiencies if present.
  • For cheilitis glandularis, consider intralesional steroid injection, topical tacrolimus or pimecrolimus, or vermilionectomy.
  • For plasma cell cheilitis, consider topical fusidic acid, topical pimecrolimus, or tacrolimus.

Is This Really Corona virus? 

We’ve been so caught up with the #Coronavirus pandemic, that we’ve missed two important developments in the field of allergy:

  1.  The FDA has now approved the use of Palforzia for taking care of peanut allergy.  Guess when this was released? January 2020, about one month prior to the outbreak of COVID-19; the affect on our practice and most other medical clinics across the country was predictable. Nothing happened except to try and avoid COVID-19 as long as possible. Hopefully, our efforts will pay off, but the viral pandemic isn’t over yet, even though the panic has appeared to lessen.
  2. I won’t talk more about COVID-19 because many of us (including myself) are suffering from Corona fatigue and plenty of good information about COVID exists on YouTube channels such as MedCram and ZDoggBe prepared to devote some time to listen to these experts, because they won’t give you just a brief summary. They drill down to the ever evolving truth about COVID-19. (definitely worth your time)
  3. Back to the peanut story. #Palforzia is designed to give minute (very small) powder of peanut protein a little bit at a time so you don’t develop anaphylaxis with every ingestion. The company making this product spent large amounts of money to train professionals such as allergists with Zoom! conferences and field representatives to make sure we launched the program of desensitization without a hitch. Then came Coronavirus and knocked that one out of the park. So where does that leave us:
  4. Palforzia or peanut desensitization still works and is available to those patients who make good candidates. And who wouldn’t be a good candidate?
  5. Palforzia is associated with some risk and a consultation just to focus on this new treatment is required before starting the process.  Can you believe, patients have to pass a certification as well?
  6. For more information, call our office at 918-495-2636 to schedule a consultation for peanut desensitization.

FDA Gives OK to Peanut Allergy Oral Immunotherapy

What else did we miss because of COVID-19?

IT’S THE SPRING POLLEN SEASON!

In years past, everyone lived their life (or especially free time) outdoors because we live in Tulsa for the Spring & Fall, right? Well, this year, it was hard to live outside when you’re quarantined. Hopefully, you avoided exposure to the Coronavirus, but you also avoided exposure to the outdoor Spring allergens (good for you). What you’ll find when we relax the “stay-at-home” rules is more sneezing, runny nose, and typical allergy symptoms. Just a great case in point at how exposure really plays a significant role in your allergy symptoms. So don’t make fun of me when I tell you to cover your mattress and pillows with a substance that isolates the dust mites! Let’s review how allergies work, because a “pollen grain” and IgE look a lot like COVID-19. the video below is a pollen grain that attaches to IgE and the process of “allergy” begins. Notice that whatever process happens in the body occurs because a receptor (suction cup on the cell) binds to a virus or IgE. Every reaction (both good and bad) happens because of this union between body cells and external molecules. Listen to the video below to see how this actually works–and BTW, infection with COVID-19 works the same way.

So how do I tell if I’m having allergy or a nasty virus?

  1. As is usual for me, I like to give you academic information on topics that I really want you to understand–don’t just take my word for it. Too many hits come up searching for “corona virus or allergy,” so I will make it simple and give you the best video to watch.
  2. Patients with allergy are always sneezing and coughing, and many stories this year involve allergy patients who were suspected of having “the virus”. One patient said, “the isle cleared at Wal-Mart when I sneezed”. Another patient found she was ostracized at a friendly get together because of her runny nose and cough–it wasn’t Corona, only spring allergies. She told me later, that she felt embarrassed and wanted to leave the party immediately. You shouldn’t have to experience this rejection and embarrassment if you know what separates virus (any type) from allergy.
  3. Viral infections will often have fever, sore muscles/joints, and in the case of COVID-19, significant shortness of breath. Most likely, this is your first experience with rhinitis, whereas allergy patients have sneezing, coughing, and runny nose year after year.
  4. If you have any questions, please ask your doctor if you need further testing. Testing for both allergies and viral infections (not just Corona) are readily available and you should take advantage of knowing how best to treat your symptoms by correctly diagnosing your problem. Now, don’t show up at your allergists’ office if you think you have COVID-19 before calling first! Don’t take my word alone, watch the video from Dr. Skoner at West Virginia — 3 minutes long and will give you the peace of mind to know “is this allergy or virus.” Your health depends on it!

 

#allergy-symptoms, #asthma, #tulsa-oklahoma

Patient Regrets

Patient: If I would have known I would live this long, I would have taken better care of myself and not smoked so much.

Me: Patients will tell you all kinds of things! And Covid-19 never crossed his mind.

COVID comments

Scientists Find Proof That Moses Parted The Red Sea - YouTube
Patient who was wearing her mask shopping at Wal-Mart told me “the isle parted like Moses and the red sea when I started coughing”. Little did everyone know that this was simply allergy and NOT COVID-19. But how do you tell the difference? Stay tuned for more stories and correct answers!

New medications for Asthma–are we at the end of the line?

Watch my FOX 23 interview about new asthma meds

Jane (fictitious name, of course because of HIPPA regulations) is now 56 years old and just last year was diagnosed with #asthma. She thought, “no big deal, there are plenty of inhalers for me to use so I don’t wheeze”.  Little did she know that 2019 would put her in the hospital 3 times and multiple visits to the emergency room because of asthma. In fact, she even missed her grandson’s graduation from kindergarten because of her asthma. Now if that doesn’t motivate you, nothing will! Continue reading

#allergies, #tulsa-oklahoma

Peanut allergy treatment is finally here!

#peanut-allergy

Tropical Nut and Fruit Co. Issues Allergy Alert of Undeclared Soy and Tree Nut (Almonds) on Their Truly Good Foods South of the Border Mix – Best Allergy Sites

Always beware that food ingredients can (and will) change over time and fortunately, good companies will alert you to the changes. TulsaAllergyNews.com

Source: Tropical Nut and Fruit Co. Issues Allergy Alert of Undeclared Soy and Tree Nut (Almonds) on Their Truly Good Foods South of the Border Mix – Best Allergy Sites

Do I really want that? Shared decision making and how this applies to allergy.

As #Christmas time approaches, it’s clear that Americans want choice. When I ask patients what they would like for Christmas, “I don’t know” is usually not their answer. Children’s eyes filled with sparkles at Santa’s coming, parents’ smiling at me and thankful I haven’t ruined their stories about Santa dominate our discussions about the holidays. Of course, I’ll always review medications and made sure that #asthma won’t ruin a perfectly good Christmas.


Continue reading

Myth-busters in Medicine

As an allergist  in Tulsa, the myths that surround asthma, food allergy, hives, hay fever abound and patients often come in to the office telling ME what they are allergic to or how to fix the problem. Let me give you some examples:

Continue reading

#allergies, #asthma, #board-certified-allergist, #dave-stukus, #food-allergy, #lynn-wiens, #tulsa-oklahoma, #zdogg