WHAT IS AN ALLERGIST?

        Allergy In Today's World – What Does The Allergist Do?

 Allergy is the term coined by Austrian paediatrician Clemens von Pirquet in 1906 in bringing together the Greek word allos meaning altered and ergia meaning reactivity. Allergy has now come to be known as a term defining altered reactivity to specific substances, which are otherwise harmless to people. 

 For an allergic reaction to take place, there must be a sensitized cell and second contact with the same antigen (allergen.) Sensitization occurs only in atopic individuals who have a tendency to be sensitized (they will develop allergic antibodies following the first contact with the particular antigen and will react following subsequent exposure to the same antigen.) The symptoms may include a dripping nose, itching eyes, sneezing, coughing, wheezing, hives, eczema, or anaphylaxis, and are caused by histamine and other chemical mediators that are released from mast cells or other cells in the body during a reaction between antigen and antibody. The responsible antibody in the case of allergic reactions is Immunoglobulin E (IgE.)

It is estimated that between 10 and 15% of the population has allergies - this would include allergic rhinitis (hay fever) bronchial asthma, eczema, urticaria  (hives, rashes) allergy to drugs, foods, latex, and insect venom. The most common allergic disease is rhinitis and this may be seasonal or perennial( producing year round symptoms). Seasonal rhinitis is due to pollen from various plants. Pollen is wind borne and the particles are light enough to be distributed by wind, particularly in dry and warm weather. Pollen from trees may include that from the maple, birch, or alder, to name but a few, or from different varieties of grasses and weeds.  It is important to note that trees, grasses, and weeds pollinate at different times and this helps in the diagnosis, together with skin sensitivity tests (allergy skin tests), to determine which pollen is the culprit in producing allergic reactions. Typically, tree pollen season starts in late March or early April and continues until Mid-June, while the grass season (in Ontario) is from the end of May until early July, and ragweed season is usually mid-August through to the first frost (usually early October). 

Patients with symptoms lasting all year might be allergic to dust mites, pets, mould, etc. Mould will be present outdoors in the air, especially on humid days following rain or melting snow. Indoor mould is often found in basements, bathrooms, or wherever humidity is high. It is important to note that in tightly insulated homes it is necessary to allow circulation of air for proper ventilation and humidity levels. It is important to maintain relative humidity in your home between 30 and 50% as humidity levels above 60% may allow moisture to build up indoors and condense on surfaces where bacteria and fungi can settle and grow. You can measure humidity with an instrument called a hygrometer which is available at most hardware stores. If you are using a humidifier in winter, be sure to clean it well and often. 

 Dust mites are small organisms invisible to the naked eye and they may be found in the cleanest of homes. They tend to gravitate to pillows, mattresses, and carpets. They prefer a more humid (over 60%) environment and dry air kills mites. Mites feed on dead skin but their faeces are highly allergenic. It is important to vacuum carpets frequently or preferably get rid of them if you are dust mite sensitive. Bed linens should be washed in very hot water, 55 degrees Centigrade kills all mites while 50 degrees Centigrade only kills about 48 per cent of them. Washing decreases antigen 20 fold. Mite proof encasings for mattresses and pillows inhibit mite proliferation.

Indoor pets are responsible for many cases of asthma and rhinitis, not only in children but also in adults. They should never be permitted in bedrooms

 Treatment of respiratory allergies such as hay fever and asthma involves avoidance of allergens whenever possible. When this avoidance is not sufficient to lessen the symptoms, then medications such as antihistamines, decongestants, steroid nasal sprays, and for asthmatics, bronchodilators and inhaled steroids may be recommended. If this treatment fails to help the patient adequately, then allergy injections known as immunotherapy or desensitization may be required.

 Allergy injections are very effective in the treatment of insect allergies as well. Patients usually need to take desensitization treatment for approximately five years to be fully protected. This would apply for near-fatal reactions to stinging insects - honey bees, yellow jackets, wasps, and hornets, collectively known as hymenoptera.

Food allergy is another area where we are seeing an increasing number of patients with reactions that run from slight to very severe. Symptoms may vary and may range from itching skin, rashes or hives, edema (swelling) or  eczema to migraine headaches, abdominal symptoms and anaphylaxis.

 Attempts to treat food allergies with immunotherapy have failed to help patients and it is crucial that these patients totally avoid foods that cause severe and life threatening reactions. It could be quite dangerous to inject food allergens that are responsible for allergic reactions as patients could develop anaphylaxis during the therapy. 

 Anaphylactic shock is an allergic emergency, and it must be treated immediately. Anaphylaxis may occur in highly allergic patients who react to peanut, shellfish, or nuts, but it can occur with any food, with drugs, following an insect sting , and in rare cases with exercise. Symptoms include generalized itching, swelling of the skin, hives, shortness of breath, low blood pressure, collapse, and if not treated immediately, death may result. Adrenaline injection (Epinephrine, Epipen, Anakit, or Anapen) is the only antidote to such an allergic reaction and it must be given promptly either by the patient or caregiver, or in the hospital.

In the case of food allergy the only treatment is strict avoidance of any food that has caused a reaction in the past. It is essential that all labels be scrutinized to determine if any of the offending food is present. It is also extremely important when eating out to ask the chef rather than the server if any of the foods known to cause allergic reactions have been used in the recipes. For anyone with serious life threatening allergies it is important to wear a Medic Alert bracelet. Patients may register with this system that keeps on file your complete medical information regarding your allergies and has a 24 hour Hotline that enables health care personnel to access your medical record. Information is available by calling 1-800-668 1507.It is also wise to tape this information to your health card. 

 Drug allergies can cause different symptoms and these include hives, rashes, diarrhoea, asthma, joint pains. The most common reaction occurs following ingestion of ASA, penicillin, and other antibiotics. Again, strict avoidance is mandatory.

Other less common allergies include allergy to latex, particularly in people who wear rubber gloves such as paramedics, allied health care workers, food handlers, and in children with certain medical conditions such as spina bifida who have frequent exposure to natural rubber latex products through surgery. Latex cross reacts with some foods and those with a latex allergy may react to kiwi, banana, chestnut, and avocado and should avoid these foods.

  Industrial allergies are complex. Because allergic people are more sensitive to different nonspecific substances such as fumes, tobacco smoke, various odours, newsprint, perfumes, most of these substances cause non-specific irritation or may aggravate present allergies in sensitive patients. Therefore, strict avoidance and elimination is recommended. After treatment with desensitization, the original symptoms often decrease and even the non-specific reactions decrease in intensity. 

  Allergy injections known as immunotherapy or desensitization treatment against specific allergens such as grass, pollen, dust mites, mould, etc. are given with small doses of allergen extract injected under the skin at certain intervals with increasing doses until the body builds specific blocking antibodies that successfully block the allergic reaction and the symptoms disappear. This form of treatment is recommended in patients if the conservative approach fails to help in rhinitis or bronchial asthma or in severe insect allergy. Treatment is highly successful but precautions have to be taken because occasionally adverse reactions to injections may occur. It should be remembered that not all patients require allergy injections.

 The injection treatment is not recommended for food allergies. The only therapy there is strict avoidance. Some of the food allergies, following a period of avoidance, will disappear over time; however, new ones may appear. Patients are advised to keep a diary to determine which food may be causing reactions.

Diagnosis depends on a detailed history that indicates the type of reactions that have occurred following ingestion of certain foods and skin testing in which a small amount of the allergen is injected into the skin and reactions are monitored 20 minutes later. It is important to note that this is the most sensitive test used in diagnosing allergy but it is not 100 per cent accurate. The RAST or blood test measures specific antibodies to the allergen in the blood and is a less sensitive yet more expensive test than the skin test. It is not covered in Ontario under OHIP.

 A challenge test used in determining food or medication sensitivities may be performed in facilities equipped with resuscitation technique equipment due to the possibility a severe reactions. In the case of food allergy, it could be the only mechanism to determine the exact culprit.

Allergic diseases are on the increase and we are not sure why this is taking place. It is very important that any patient who suspects an allergy first consult with the family physician and, if warranted, obtain a written referral note to an allergy specialist. If the situation is unclear or complicated, then it is important to request referral to an allergy specialist. At times an allergist may be able to sort out multi-system problems which puzzle other physicians. A detailed history will be taken and a physical exam performed along with any necessary allergy skin tests or other ancillary tests in order to arrive at a carefully considered diagnosis. A treatment plan will then be suggested.

 Patients can live comfortably without fear if they know what to avoid, how to treat their symptoms immediately, and when to seek additional medical attention. This information should be discussed at a consultation with an allergist.

 For more information and printed materials on allergy and asthma, including the document, Anaphylaxis in Schools and other Child Care Settings, please contact the Allergy Asthma & Immunology Society of Ontario  HOTLINE at 416 633 2215 or by fax at 416 633 3108.

                                                                    GLOSSARY

ANAPHYLAXIS                    A SEVERE OR EXTREME TYPE OF ALLERGIC REACTION

                                                THAT MAY BE LIFE THREATENING

ANTIBODY                           A PROTEIN SUBSTANCE DEVELOPED IN RESPONSE TO

                                                AND INTERACTING WITH AN ANTIGEN.

ANTIGEN                              ANY FOREIGN PROTEIN OR OTHER AGENT THAT

                                                STIMULATES THE PRODUCTION OF ANTIBODIES

IgE                                          ANTIBODIES  THAT ATTACH TO CERTAIN CELLS AND

                                                TRIGGER THE MEDIATOR RELEASE THAT PRODUCES

                                                IMMEDIATE ALLERGIC SYMPTOMS

IMMUNOTHERAPY           DESENSITIZATION THERAPY THAT INVOLVES A

                        SERIES OF INJECTIONS OF ALLERGENIC EXTRACTS

                        GIVEN TO A PATIENT WITH ALLERGIES 

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