Cicadas Hanging Out

Are you surviving the Cicadas? They are everywhere, around my house, yet many of my patients have only seen them on the news and in the newspaper.

Are you grossed out by all the talk and special  TV programming directed towards cicada recipes? I know I've seen enough.

Did you know that there may be a risk of having an allergic reaction to cicadas if you eat them, particularly if you are allergic to shellfish? I recently read about this issue and googled it. I have a site which describes a case report posted below.

Bottom line: The cicadas are here. They are not everywhere though. Avoid eating them if you are allergic to shellfish.

Case Report on a person who had an allergic reaction after eating 30 cicadas:  www.aafp.org/afp/20050601/letters.html

My posting on "Asthma and Tobacco Smoke" is almost ready (Stay Tuned!).

Effective but may be habit forming

Rhinitis Medicamentosa (RM) is a disease brought on by extended use of topical nasal decongestants. “Rhinitis” means nasal (rhino= nose) inflammation (“-itis” = inflammation). Medicamentosa means medication; hence nasal inflammation from medication.

There are several brands of nasal sprays for stuffy nose available over-the counter (OTC). These are most often chosen to relieve symptoms associated with common cold, allergies or sinus infection. Recommendations (package insert) usually include avoiding use beyond 5-7 days. When used for more than 5 days the nose becomes progressively less responsive to each dose. The duration of the decongestant effect becomes shorter as more doses are taken. The result is that you get hooked on the medicine and suffer from rebound congestion after laying off of it for a while. The rebound is a sudden feeling of rapidly worsening nasal congestion which leads to using more nasal spray.

It is not uncommon for people with RM to buy 2-3 nasal sprays at a time and overuse the sprays to the level of taking 12 to 20 doses a day (usually recommended between 2 and 4 times daily depending on the formulation). People with RM develop dependency because of the rebound effect. The inside of the nose often sustains damage because of the constant vasoconstriction (narrowing of small arterial blood vessels which decreases blood flow to the surrounding nasal tissue).

I see between 10 to 25 new patients a year with RM. Some reports have estimated about 1% of the population having this problem.

How do you know if you have RM?

If you have been using an OTC nasal spray for nasal congestion for more than a week (daily) and are unable or unwilling to go a day without taking a dose, you most likely have RM.

What can be done about it?

Most importantly, just realizing that you have a problem related to the medicine overuse, and the associated dependency may be helpful in curing the problem. Just stopping the nasal spray leads to resolution, but this is often difficult. Your doctor can assist you by prescribing a topical nasal steroid and oral decongestant (usually pseudophedrine or phenylephrine tablets). There are potential side effects associated with oral decongestants which should be considered, so a doctor’s guidance is important. Occasionally an oral steroid may be prescribed for a period of 5-10 days (tapering dose).

What if one continues to use the OTC nasal decongestants for months to years?

Severe damage to the inside of the nose may follow prolonged RM. Nasal irritation, bleeding and perforation of the septum (the midline wall) may occur. Scarring of the inner lining of the nose may lead to chronic dysfunction of the nose.

Remember, RM can be avoided by not over using OTC nasal spray decongestants. I rarely recommend them at all to my patients. I warn those that choose to use them to limit use to only 3 days, less than 3 times a year. I think children should be kept completely away from OTC nasal spray decongestant. Allergy sufferers should stick to prescribed antihistamines, oral decongestants and nasal steroids which are much more safe and effective in the long run.

Want more detailed information?

Try: www.answers.com/topic/rhinitis-medicamentosa

Next Topic: Tobacco Smoke and Asthma Control (a smoke free home and body is essential)

The nose has several functions which contribute to maintaining good health. Besides being a place to hang our eyeglasses, the nose conditions the air for our lungs, filters out particles and germs, allows us to detect odors and fumes through the sense of smell (as a warning system), represents the preferred route for getting air to the lung (the mouth is the alternate path), and may enhance (or decrease) one’s appeal. Does your nose make you more attractive?

The nose is capable of adding liters of water to air breathed into the nasal passages (when the air is dry). The nose is the first line of defense against germs suspended in the air. A number of events may disturb the normal function of the nose.

The common cold (viral nasal infection), allergic rhinitis (hayfever) and sinusitis (bacterial infection of the nose and sinuses)  most commonly disrupt nasal function. Many medications have become available for treatment of these disorders but a number of people have failed to adequately respond. Some rhinitis sufferers experience excessive drying of the nasal passages when on antihistamines (for example Benadryl, Allegra, Zyrtec and many others). Nasal steroid sprays are frequently prescribed for allergic nasal problems but have potential drawbacks which include nasal irritation and bleeding. Most people take prescribed antihistamines and nasal steroids without adverse effects but a small percentage have problematic side effects.

Imagine how your sinuses feel after a nice hot bath or shower.

Ever notice how your sinuses clear out after a swim in the pool or a lake?

Most over-the-counter (OTC) nasal saline sprays are formulated for moisturizing the inside of the nose. Even when properly used these sprays do not reach the deeper recesses of the internal nasal passages.

Nasal irrigation or rinsing has increasingly been recommended by Ear Nose and Throat specialists and Allergists, for patients with chronic nasal sinus problems, colds and sinusitis.

A number of nasal rinse systems are commercially available (no prescription needed). I have provided links to two popular systems: SinuCleanse which offers the Neti Pot and other alternative units, and NeilMed nasal rinse system.

The Neti Pot dates back thousands of years and has been taught by Yoga instructors in a comprehensive program addressing many different ailments (chronic nasal and sinus problems, visual problems, ear problems and lung problems, as well as stress relief and overall respiratory function). The nasal rinsing is quite thorough when done correctly. Over a cup of saline (salt water) runs through the nasal passages under the force of gravity. People that attempt to use the Neti Pot without good instruction may be frustrated by the lack of effectiveness. I recommend watching the video provided on the SinuCleanse site, and completely reviewing the written instructions if you choose to use it. I think nasal rinsing may be too difficult for young children but there are exceptions.

NeilMed has two different size bottles for nasal rinsing. Saline is used in a plastic bottle which you squeeze, in order to force a stream of water through the nasal passages. Proper technique is again, important for good results. Squeezing too hard may result in nasal irritation, headache and ear plugging. Be careful to keep your head flexed downward and try not to use suction (pull the bottle away from the nose to allow air back in, then reposition for squeezing).

With both NeilMed and Neti Pot systems, having the mouth open and continuing to breathe through the mouth is important. The head should be flexed downward, over a sink or basin and slightly tilted away from the hand-held unit. When done properly (with both systems) water streams in through one side of the nose and out the other.

Poor technique is not the only reason the nasal irrigation may not work. Deviated septum, extremely plugged nasal passages, a very sensitive gag reflex and unusually large Eustachian tube openings (opening in the back of the nose-throat area that leads to the middle ear compartment) may cause difficulty with nasal rinsing. Some people may struggle with this process no matter what. These systems are not for everyone but a lot of people get very good results.

I think it’s important to note that nasal rinsing is a potentially good way to enhance your upper respiratory health when struggling with recurrent colds, sinus infections, allergic rhinitis or asthma. The rinsing process is no substitute for prescribed allergy medications, allergy shots or antibiotics (when indicated).

Furthermore, fewer people experience irritation when attempting to irrigate the nose when they have carefully prepared the saline and warmed it a bit. Cold or hot water may irritate the lining of the nose. Wrong amounts of salt or iodized salt may also be less well tolerated. Non-iodized salt and a small amount of bicarbonate (baking soda) help to make a more soothing solution. Both systems come with readymade, preservative-free , salt packets which make it much easier to make the saline. The packets are simply dumped into a measured amount of distilled or boiled (and then cooled ) water, in the case of NeilMed. SinuCleanse recommended running warm water from the faucet then adding the packet.

For more information about SinuCleanse (Neti Pot) go to: www.sinucleanse.com

The NeilMed site is : www.unimedprod.com/

Interested in more historical facts about Neti Pot (Jala Neti- Sanskrit term for “water cleansing”)?

 Check out:   (you may have to copy and paste this link)   en.wikipedia.org/wiki/Jala_neti  

For my patients tuning in:

I think nasal rinsing may assist you in good nasal inflammatory control. I have probably instructed you to take your prescribed nasal spray medication after a bath or shower. If you do nasal rinses, you may take your nasal spray after clearing out the residual moisture (saline). The after shower routine would not be necessary (your choice).

Let me know that you saw this posting at your next appointment. I will spot you an extra sample of something (if available).

Next Stop: Rhinitis Medicamentosa (over-use of OTC (over-the-counter) nasal spray decongestants)

Easy to avoid? Just read on.

George Washington Carver was a highly intelligent African American artist, poet and scientist who spent many years doing research on peanuts in the 1800s. He discovered over 300 uses for the peanut as well as 100 uses for the sweet potato. Of course, had he developed peanut allergy in childhood, he would have never been able to carry out the multitude of experiments which led to his amazing discoveries. In fact, had he been markedly sensitive to peanut, just being in the same room or lab where the experiments were carried out, may have caused fatal throat swelling or suffocating respiratory symptoms. I believe, had Carver known peanut allergy would be so widespread 150 years later, he would have worked out a cure.

Peanut allergy is the most common severe food allergy of childhood. 1.5 million Americans are allergic to peanut. Some studies have estimated a doubling of the number of children with peanut allergy in this country in past years.

There is increased risk of developing peanut allergy in children born to parents that have food allergy, or a history of food allergy. Peanut allergy should be suspected if there is a rash, choking, gagging, itching, hives (welts), or complaints of throat swelling, tongue swelling or difficulty breathing after eating peanuts or a food with peanuts in it. Other symptoms may include stomach pain, cramping and diarrhea, swelling of other areas of the body, dizziness or fainting. These are most but not all of the possible symptoms.

If someone has any unusual sensation or feeling after eating peanuts (or any food) they should avoid it until discussed with their doctor. Young children may simply stop eating or spit the food out. It is important to consider whether the rejection may be because of throat discomfort, particularly in the case of peanut or a food with peanut or other high risk food in it (tree nuts, shellfish or other sea food).

When peanut allergy is suspected, it should be confirmed by either a skin prick test or a blood test. Sometimes both tests are ordered in order to be certain whether there is allergy. Once confirmed, strict avoidance is key. Careful reading of food labels and asking waiters and waitresses about whether a dish or food has peanut in it is essential.

An “Alert” bracelet or necklace is recommended for older children or adults. An Epinephrine containing device is usually prescribed, just in case there is accidental exposure.

About 50% of severe reactions that occur in the U.S. are by accidental exposure. Unfortunately 50-100 deaths occur annually in the U.S. from peanut allergy. 80% of fatalities and life threatening food reactions in children are related to peanut (in the U.S.).

Realize that mild initial or multiple reactions may precede a more severe life threatening reaction. Fatal and near fatal reactions have occurred on the apparent first ingestion of peanut but this is not common.

It is important to learn as much as you can about peanut allergy and how to avoid them if you or your child is allergic to them. I have included a website that goes into further detail below.

Although only about 20 to 25% of children lose their hypersensitivity to peanut over time, I recommend (to my patients) re-testing every 3-5 years in milder cases, to allow for some easing up on the restrictions if indeed tests become negative. There are reports of some people having negative allergy tests (to peanut) after having previous allergic reactions (and earlier tests positive), followed by eating peanut without problems, but then later on having an allergic reaction to peanut. This means that hypersensitivity can go away but then perhaps return in some individuals. We therefore have the majority of our patients understand that peanuts should be avoided indefinitely, to be safe.

Should children allergic to peanut avoid all nuts?

You may not get the same answer from 2 different allergists. I recommend (especially in the case of children) avoiding all nuts which include the family of tree nuts (pecans, almonds, walnuts…) even if they were previously well tolerated. Cross contamination may lead to accidental exposure. Cross contamination may occur if other types of nuts are processed in the same machines or containers as peanut. There may be cross contamination with utensils.

Did you know that peanuts are not real nuts?

True nuts are tree nuts (listed above). Peanuts are in the legume family (peas, soybean, and other beans). Fortunately, many people allergic to peanuts are still able to eat other members of the legume family, such as beans (but there are exceptions). Restriction orders should be reviewed by your doctor.

There are many investigators working on other ways to treat peanut allergy. Our approach to this problem may change in future years.

The website for more information is:

www.mayoclinic.com/health/peanut-allergy/DS00710

Want to learn more about George Washington Carver?

Go to: www.lib.iastate.edu/spcl/gwc/home.html

Next week: Nasal Saline Treatment: Moisten, Rinse or Irrigate?

Above: Three Yellow Jackets (Often the more aggressive of venom insects which tend to have nests located in the ground)

Spring is finally here. Leaves are popping out of their buds, perennials are starting to bloom and warm weather has rescued us from the winter doldrums.

As we begin to spend more time outdoors, let our car windows down and raise our windows up at home, the downside of late spring and summer begins to surface.

What can float like a butterfly and sting like a bee? No, not "The Greatest" (Muhammad Ali).  I’m talking about Yellow Jackets, Hornets, Wasps and of course, Bumble Bees (or Honey Bees).

If you have ever been stung by one of these insects, you know that the pain and soreness, which may linger for days, makes you dread the thought of being stung again.

Here are some stats that may be of interest to you:

Insect stings are very common in the United States.

About 9 million people in the U.S. have had a systemic reaction (potentially severe allergic reaction that may involve the skin, throat, lungs, stomach and heart) to an insect sting.

Approximately 50 million people are hypersensitive to insect venom and therefore are at risk of having an allergic reaction.

There are about 50 deaths annually in the U.S. from insect venom stings.

What should you do if you are stung by a bee or other venom containing insect?

First, try not to panic. The majority of people stung survive and do not require emergency care. If this is the first ever insect sting we tell our patients to apply a cold compress and elevate the extremity (if an arm or leg). We tell them to take some Benadryl if available but remember it may cause drowsiness. We alert them to signs of a systemic reaction, which we consider a medical emergency.

When do you call 911?

We instruct our patients to call 911 if there are any signs of breathing problems or chest symptoms (shortness of breath, chest tightness or pressure, choking or gagging); if there is dizziness or lightheadedness, fainting or altered mental state; if there are any signs or symptoms of throat closure or swelling (lump in throat sensation, trouble speaking or swallowing). Call 911 immediately if the above symptoms occur after an insect sting (Use your injection device first, if you have one- see below).

Who should have an Epinephrine device?

Anyone that has previously had a systemic reaction (even if just a few hives) should carry a device to self-administer epinephrine, in case of a future sting. If an insect sting is followed by throat symptoms, trouble breathing or light-headedness, the epinephrine should be given, followed by a 911 call. Epinephrine may wear off after 10 to15 minutes.

Who should have venom testing?

This depends on the age of the patient and characteristics of the reaction. If someone under 16 years old is stung and only has hives (even if all over) and some swelling limited to the skin, venom testing and shots are not necessary. There is not a high risk of a later insect sting causing a severe systemic reaction. On the other hand, if a child under 16 years has throat, lung, heart symptoms or light-headedness, after an insect sting, venom testing should be done.

If you are 16 years or older, venom testing should be done if there were hives or swelling away from the sting site, or if there were throat, lung, cardiovascular symptoms or dizziness.

Local reactions (swelling, redness, itching or pain only at the site and area surrounding the site of injection) do not require venom testing or shots. Some people have large local reactions (extreme swelling and often discomfort at and around the site of the sting) but still are not at high risk for a severe systemic reaction if stung again. We usually do not do venom testing even if a large local reaction has occurred.

Venom testing should be done by an allergist. Venom Immunotherapy (VIT) also referred to as venom shots, are recommended if venom testing is positive to any one or more insect venoms.

Is there a blood test for venom allergy?

Yes, there is a blood test called RAST test which measures the presence of IgE antibody specific to venom. Results may be false positive (suggest allergy to venom but be wrong) and sometimes false negative (be negative in a person that actually is allergic to venom).

Skin testing is the more accurate test but because occasional false negatives do occur, blood testing may be ordered to confirm the results.

How long should you be on venom shots?

We generally have people on VIT for 5 years, and then sometimes retest before stopping them. People that have had a severe life-threatening allergic reaction may be advised to stay on shots several years past the 5 year point or until repeat skin tests are negative.

What if you had a systemic reaction to a sting but decided against getting tested or having shots?

An older child or adult who has had a systemic reaction has a 40-60% chance of having a severe systemic reaction if another sting occurs within months to several years. If it has been more than 15-20 years, the chances of a systemic reaction may be less than 20%.

VIT lowers the risk of having a severe venom reaction to less than 3%. This markedly lowered risk is sustained for years after the shots have been stopped (assuming 3-5 or more years of venom shots).

Young children tend to have a lower risk of systemic reaction to insect stings.

In Review:

Insect venom stings may cause a localized (just some mild pain and swelling at the site of the sting) or systemic (things occur away from the site where stung; hives, throat symptoms, shortness of breath, lightheadedness- suggesting a drop in blood pressure).

Systemic reactions can be fatal and should be treated immediately. Call 911.

You should have means of giving yourself or child an epinephrine shot if there has been a history of a systemic reaction following an insect sting. Epi-Pen (Epi-Pen Jr. if under 60 pounds) or Twinject. A prescription is required.

Children, under 16 that have only had a local reaction or systemic reaction limited to the skin, do not require a shot of epinephrine or venom testing. Having epinephrine available (in the case of having had a previous skin only, systemic reaction) may be advised by your allergist.

Other Tidbits:

-If you are stung and a stinger remains in the skin, you were stung by a bumble bee or honey bee (all the other venom containing insects do not leave there stinger). The honey bee and bumble bee have a jagged edged stinger. Once they sting you they die shortly afterwards.

-Do not attempt to pull out a stinger with your fingers or tweezers. The bumble or honey bee leaves the stinger and part of its venom sac after stinging you. If you squeeze it, more venom squirts into the site. The better approach is to allow a nurse or other health care provider remove it properly. Teasing it out with a clean edge of a card or needle sometimes works.

-Read more about ways to avoid getting stung. Some suggestions include: avoiding perfumes or colognes when going outdoors; avoid bright pastel colors; avoid wearing sandals, wide bottomed pants and long open sleeves; avoid having open sodas (insects may fly into the can or bottle) which attracts them; do not sit next to garbage cans; avoid sudden sweeping movement to wave them away (may irritate them).

Next Week: Peanut Allergy: Update on what we know

The drawbacks of getting allergy shots are; the inconvenience of having to go to the doctor's office, weekly (early on); the risk of having a local or systemic reaction (small risk but may be severe) ; and the fact that it must be an injection, Ouch! (a needle is involved).

The upside of allergy shots are; they are effective about 80% of the time; they have been given for decades (suggesting good long-term safety) ; they are the most effective process of desensitization currently available; they are FDA (Food and Drug Administration) approved; and they have some degree of standardization. Standardization means that units of measure addressing quantity and potency exist for comparing extracts (the material used for injection) made by a particular company (that makes the extract) and between companies (other manufacturers). Furthermore, the experience with multiple allergen injections (grasses plus trees, dust mite etc.) is widespread. Most people are sensitive to more than one allergy trigger.

The upside of SLIT is primarily the safety factor (extremely rare severe allergic reactions). Sublingual (under the tongue) immunotherapy may therefore be given at very young ages (in Europe, under 5 years of age). Home treatment (self or parent guided) has been allowed in many settings. A significant number of children and adults respond to this treatment (many clinical studies have shown improvement). Hence, safety and convenience are the main factors.

So what's the downside of SLIT? It is not FDA approved in the United States. There are no established standards for measuring the quantity and potency of extracts from different companies. Although only a few studies comparing SLIT to SCIT (under the tongue desensitization to allergy shots) have been published, SCIT (allergy shot) is almost twice as effective as SLIT. Finally, SCIT has primarily been done with one major allergen (just a particular pollen or just dust mite). The experience of SLIT with multiple allergens is scant. There is some evidence that single allergen desensitization may reduce the development of additional allergen sensitivities (for example, sublingual therapy to grass may reduce, especially in a young child, the development of ragweed or dust mite allergy in later years). This tendency has also been shown for SCIT.

Conclusions: Allergy injections (SCIT) are a good, proven means of reducing allergic sensitivity for the management of allergic rhinitis (hayfever), asthma and venom hypersensitivity (Bee sting reactions). They are the preferred method of immunotherapy in this country. SLIT is still under evaluation (not FDA approved) but may become more available in future years. Clinical studies show promise but a few important hurdles need to be reached (standards of measure, better results and multiple allergen treatment).

SLIT therapy is offered in the United States, as are many other alternative therapies. I recommend consulting with a board certified allergist if you are thinking about it. Most allergists will share the above points with you.

For more about allergy shots go to April (Navigation Bar) and scroll down to the bottom. Hit page 2 ("Next page" in April section-- posted April 7th).

Stay Tuned!

"Bee Sting Allergy" coming up next.