Stinging insect allergy affects approximately 3% of adults and 0.4-0.8% of children in the United States, with 40-100 people in the United States dying each year from a sting reaction. This type of allergy may develop at any age, is not inherited, and can occur whether or not one has other types of allergies. People with a severe allergic reaction to an insect sting have usually tolerated a prior sting; it is rare to have a life-threatening reaction the first time a person is stung. The insects responsible for the most serious allergic reactions are honey bees, wasps, hornets, yellow jackets, and fire ants. Bumblebees rarely sting.
Reactions to insect stings fall into two categories: anaphylaxis and large local reactions.
Anaphylaxis is defined as a sudden onset life-threatening allergic reaction. Onset of symptoms can be immediately to within 2 hours after a sting. Symptoms may include hives, swelling, difficulty breathing, wheezing, coughing, a feeling of throat closing or throat tightness, nausea, vomiting, low blood pressure, lightheadedness, shock, or loss of consciousness. In other words, any symptoms distant to the site of a sting may be life-threatening. However, if a person is stung and only has swelling at the site of the sting with no other symptoms, this is called a large local reaction.
People who have a large local reaction to a sting are not at increased risk of a life-threatening reaction to future stings; they do not necessarily need evaluation or treatment by an allergist. However, once a person has had a severe reaction to a sting (anaphylaxis), there is a 50-65% chance of having a similar or more severe reaction if stung in the future. Anyone who has experienced symptoms consistent with anaphylaxis after an insect sting (or symptoms distant to the sting site) should be referred to an allergist. They will need an evaluation and consideration for venom-specific immunotherapy in order to minimize the likelihood of future reactions. The exception is children under 16 years of age who only develop hives but no other symptoms after a sting. They are not at increased risk of anaphylaxis with future stings, and do not need an allergy evaluation or consideration for treatment with venom-specific immunotherapy.
The allergist will take a detailed history to confirm the nature of the sting reaction. The insect culprit will be identified if possible. Insect allergy is then diagnosed with venom allergen skin prick and intradermal testing. Occasionally, blood testing for venom allergy may be performed to complement skin testing. Because there is cross-reactivity between some venoms and it is not always possible to identify the insect responsible for the reaction, testing for all relevant venoms is usually performed. Venom skin testing accurately identifies >90% of stinging insect venom sensitivities.
Treatment and Practical Tips
Treatment of stinging insect venom allergy consists of venom-specific immunotherapy, the recommendation to carry injectible epinephrine, and observing general avoidance measures to reduce the risk of being stung in the future. The allergist may also provide a written anaphylaxis action plan and recommend obtaining a medical-alert bracelet which states that the wearer has stinging insect venom allergy.
Venom-specific immunotherapy reduces the risk of an allergic reaction to a future sting from 50-65% to under 5%. It exposes the patient’s immune system to gradually increasing doses of the venom(s) to which they are allergic. This produces tolerance to the venom(s) that protects them against anaphylaxis if stung again. Venom-specific immunotherapy is typically given for 3-5 years. It is 98% effective in preventing future systemic reactions and is the standard of care for treating venom-allergic patients. Venom immunotherapy can be a life-saving therapy.
Epinephrine is the cornerstone of treatment for all forms of anaphylaxis. All patients with a history of stinging insect venom anaphylaxis should carry epinephrine at all times and be properly instructed in its use. Epinephrine should be administered immediately at the onset of any life-threatening symptoms consistent with anaphylaxis and should be followed by transport to the nearest emergency room for additional care. Because epinephrine is short-acting (15-20 minutes), symptoms of anaphylaxis may recur after the epinephrine wears off. The use of this medicine is therefore considered a temporizing measure, not a substitute for seeking medical care. An antihistamine such as Benadryl should also be used, but only after epinephrine has been given.
General avoidance measures to reduce the future risk of a sting include the following:
1. Avoid wearing perfumes and scented lotions, which may attract insects.
2. Wear shoes (closed-toed) outdoors at all times.
3. If eating outdoors, keep food covered until eaten, and leave the clean-up to others.
4. Exercise caution when eating sweet foods and drinks (sodas, juices) outdoors.
5. Avoid or exercise caution around pools, picnic tables, and trash cans.
6. If possible, leave yard-work, gardening, and landscaping to others; otherwise proceed with extreme caution.
7. Have periodic inspection of your home and property by a professional pest company or non-allergic relative or friend to exterminate nests.
Do you have problems with coughing, wheezing, or chest tightness when you exercise? Do you feel very tired and short of breath when you exert yourself? Some people wrongly believe that they are just out of shape when, in fact, they may have exercise-induced asthma. About 18 million Americans have asthma and, of those, 80% will have increased symptoms with exercise. In non-asthmatics, up to 15% experience asthma symptoms with exercise and 40% of people with nasal allergies may experience exercise-induced asthma symptoms.
What is Exercise-Induced Asthma?
Exercise-induced asthma (EIA) is a reaction of the lungs caused by exercise. The bronchial tubes become irritated and constrict, also known as bronchospasm. Excess mucus is also formed contributing to the blockage of the airway and congestion. It is thought that when you exercise the airway is cooled and dried rapidly which sets off the reaction in some people. Although chronic asthma sufferers are more likely to have EIA, the presence of EIA does not lead to chronic asthma.
Symptoms and Triggers
Symptoms of EIA include shortness of breath during or after exercise, coughing, wheezing, chest tightness or pain, and extreme fatigue. Symptoms usually start within 5-20 minutes after starting exercise and may last for 30-60 minutes. Sometimes symptoms start only after activity has stopped however. “Locker room cough”, or a cough that occurs after exercise, is a common form of exercise induced asthma. Shortness of breath, from poor conditioning, usually resolve within a few minutes of rest. People with EIA are overly sensitive to sudden changes in temperature and humidity. Colder, drier air is usually more of a problem. Nasal breathing helps warm and humidify the air you breathe so mouth-breathing with exercise reduces the moisture and humidity of the air that reaches your lungs. Air pollution, high pollen counts, and viral upper respiratory infections can also worsen wheezing with exercise.
You should talk to your doctor if you think you may have EIA. You will need a good history and physical which often leads to the diagnosis. You may have a resting lung function test to make sure you have no chronic asthma. You may also have a breathing test after exercise, although this test may not be positive in everyone with EIA. A trial of bronchodilator therapy prior to exercise may be used to help determine whether you have EIA. Chest pain may be a symptom of EIA, but it is important for your doctor to rule out cardiovascular disease as well.
Treatment and Practical Tips
There are things that you can do to reduce the chance of having symptoms. Staying out of cold, dry air is a big factor so train indoors if possible. If you do exercise in the cold, try to breathe through the nose as much as possible, wear a mask or scarf, and avoid exercise in the cold if you have a respiratory infection. Warming up 45-60 minutes before training or playing may help. Taking frequent, short breaks can help. Avoid training or playing outside on days with high pollution or pollen counts. Certain sports are tolerated more than others. Swimming is usually tolerated well due to the humidity of a pool. Lower intensity sports like golf, baseball, and weight lifting are better tolerated. Sports with short bursts of energy such as baseball, football, wrestling, gymnastics, and short-term tack events are better tolerated than soccer, basketball, hockey, skiing, and long-distance running. Always have your asthma medications with you!
The first step of treatment is the use of an inhaled short-acting bronchodilator medicine 15-20 minutes before exercise. These include albuterol, pirbuterol, and levalbuterol and are effective in 80-90% of patients, have a rapid onset of action, and last for 4-6 hours. If symptoms are not controlled by these short-acting medications, a daily medication may have to be used to prevent inflammation and responsiveness of the airway.
Most importantly, you should be evaluated and continue to exercise. Exercise and training will improve fitness, reduce the amount of breathing needed with exercise, and allow you to exert yourself at a higher intensity before symptoms begin.
With the arrival of spring, we can expect warmer weather, leaves on trees, flowers everywhere and- 'pollen'- a word most allergy sufferers are reluctant to hear. Seasonal allergic rhinitis also called “hay fever” can affect your quality of life.
Symptoms include sneezing, stuffy nose, itchy, watery eyes, and runny nose. For some people allergies can also trigger symptoms of asthma.
The most common outdoor allergens include tree pollen, which is observed in early spring followed by weed and grass pollen. Mold exposure occurs year round in most climates except during periods of snowfall.
Other allergens that can trigger symptoms include dust mites and pet dander- the so-called 'perennial' allergens.
Allergists can diagnose the exact allergens that are triggering your symptoms by skin and/ or blood tests. Various treatments for allergies include making changes in your environment and lifestyle, medications, and if necessary allergy shots (allergen immunotherapy).
It is important to diagnose and treat allergic rhinitis because untreated allergies can be associated with complications such as asthma, sinusitis, otitis media (ear infections) and nasal polyposis.
You can learn more about your allergies and asthma by contacting me at
My staff and I at Allergy Partners of Chicago are always here to help.
Dr. Mona Hirani
This inflammation prevents the esophagus from functioning normally and leads to symptoms. EE commonly occurs in people with other allergic diseases such as allergic rhinitis (hay fever), asthma and/or eczema.
Reflux that does not respond to usual therapy:
- Dysphagia (difficulty swallowing)
- Food impactions (food gets stuck in esophagus)
- Nausea and vomiting
- Failure to thrive (poor growth, malnutrition or weight loss)
- Abdominal or chest pain
- Feeding refusal/intolerance or poor appetite
- Difficulty sleeping
The only way to definitively diagnose EE is through endoscopy with biopsies, usually done by a gastroenterologist. The endoscopy is often performed after treatment with reflux medications have failed to relieve symptoms. During the endoscopy, the gastroenterologist looks at the esophagus, stomach and duodenum (the first part of the small bowel) through an endoscope (small tube inserted through the mouth) and takes multiple biopsies (small tissue samples) which a pathologist reviews under the microscope. A high number of eosinophils (>15 per high power field under the microscope) suggests a diagnosis of EE.
Once EE is confirmed, allergy testing is recommended as many patients with EE have underlying food and possibly environmental allergies that are contributing to the abnormal inflammation seen in the esophagus. The most common type of allergy testing is skin prick testing, but patch testing to certain foods can be useful as well. In patch testing, a small amount of the foods is placed on the skin (usually the back) and covered with tape for 48-72 hours. At that point, the site is assessed for evidence of redness and inflammation indicating food allergy.
At present the two main treatments recommended are dietary management and topical corticosteroids.
Elimination Diets – All “positive” foods on allergy testing are removed from the diet. Often this is the only treatment needed.
Six-food Elimination Diet – Patients eliminate the top 6 most allergenic foods (dairy, eggs, wheat, soy, peanuts/other nuts, fish/shellfish).
Elemental Diets – All sources of protein are eliminated from the diet except for an amino acid (building blocks of protein) formula. These diets are mostly used in young children with EE.
Food Trials – This involves adding back one ingredient at a time to one’s diet to determine specific foods causing a reaction. They begin after symptoms resolve and eosinophils have cleared.
Medications - Medications most commonly include steroids to control inflammation and suppress eosinophils. They can be taken orally (a form of prednisone) or topically (swallowed asthma inhaled steroid such as fluticasone or budesonide).
How We Can Help
The diagnosis and treatment of eosinophilic esophagitis requires a multidisciplinary team approach involving gastroenterologists, allergists, nutritionists. As part of the nation’s largest allergy practice, Allergy Partners’ physicians provide the expertise needed to accurately diagnose underlying allergic triggers to EE. With this information, a personalized and comprehensive treatment plan aimed at alleviating symptoms of EE can be formulated.
Category: Food Allergies; Treatments
Frequently, I am asked about the difference between wheat allergy, celiac disease and gluten sensitivity. This is a complicated issue that has many different components. Gluten is a protein that is found in foods that have been processed from wheat and related grains including barley and rye. The diseases listed above represent distinct abnormal responses to either gluten or wheat.
Classic wheat allergy is closely related in pathogenesis to other classic food allergies, like peanut allergy. These conditions are termed IgE-mediated diseases because of the specific type of immune response that leads to symptoms. Other examples of IgE-mediated diseases include hay fever (allergic rhinitis) and some types of eczema and asthma. The symptoms of a classic wheat allergy may include hives or skin rash, vomiting, diarrhea, stuffy/runny nose, sneezing, wheezing, throat constriction or shortness of breath. These symptoms almost always occur within 2 hours of ingesting wheat. Large-scale studies of wheat allergy in the U.S. have not been conducted, but it’s estimated that approximately 0.4 – 0.5% of our population is allergic to wheat. Wheat allergy is typically outgrown by adulthood in about 65% of children. In terms of diagnosis of classic wheat allergy, there are both blood and skin tests that measure wheat IgE. The accuracy of these tests is moderate at best, so we sometimes have to perform food challenges (asking the patient to ingest wheat in a safe controlled environment like the clinic) to really determine if they have classic wheat allergy. If someone is truly wheat allergic, then strict avoidance of wheat is the cornerstone of management as well as treating any accidental ingestions with subsequent reactions appropriately (if severe reaction, epinephrine is used).
Celiac disease is a condition in which the immune system responds abnormally to gluten, which can cause damage to the lining of the small intestine. Celiac disease is also known as gluten sensitive enteropathy, celiac sprue and nontropical sprue. The abnormal response of the immune system in this disease is completely separate than that of classic wheat allergy. Because of this, the symptoms are different and the way we diagnose this disease is distinct. Prototypical symptoms of celiac disease include diarrhea, weight loss, abdominal discomfort or excessive gas. Because this disease in based in the gut, malabsorption can also be seen and lead to other diseases including osteopenia/osteoporosis and iron deficiency anemia. Other associated diseases can include diabetes mellitus, thyroid problems (usually hypothyroidism), dermatitis herpetiformis (intensely itchy, blistering skin rash that affects 15 – 25% of people with celiac disease), nervous system disorders and liver disease. Diagnosis of celiac disease consists of either a blood test and/or small bowel biopsy (the latter being the gold standard test). Both of these tests require that the patient continue eating a normal diet, including foods that contain gluten, at the time of sample collection. The cornerstone of treatment for celiac disease is complete elimination of gluten from the diet for life. Gluten is not only contained in the previously mentioned grains; it is also hidden as an ingredient in a large number of prepared foods, as well as medications and supplements. There are many on-line resources to help patients find safe foods and products, but it can be very difficult. Unlike classic wheat allergy, where the patient only needs to strictly avoid wheat, in celiac disease the patient must avoid all gluten containing products like wheat, rye and barley as well as many processed foods.
Gluten sensitivity is a different reaction to ingesting gluten. Symptoms can arise throughout the body and range from bloating, abdominal discomfort, pain or diarrhea to headaches and migraines, lethargy and tiredness, ADHD, muscular disturbances, neurologic symptoms as well as bone and joint pain. A study from the University of Maryland Center for Celiac Research shows that gluten sensitivity is a different clinical entity versus celiac disease. A different immune mechanism, the innate immune response, comes into play in reactions of gluten sensitivity, as opposed to the long-term adaptive immune response that arises in celiac disease. Researchers believe that gluten sensitive reactions do not engender the same long-term damage to the intestine that untreated celiac disease can cause. These same researchers believe that this disease affects up to 6% of the population (but it is unclear to me how they come about determined this figure.) There is no direct test for gluten sensitivity. The only “test” is a trial of a strictly gluten free diet. I recommend to my patients to try this for one month to see if their symptoms improve. After that month, reintroduce gluten. If the symptoms decrease on the gluten-free diet and the re-emerge upon reintroduction, then gluten may very well be the cause. As with celiac disease, the only treatment is to strictly avoid gluten. For those who are interested in a more detailed, medically oriented analysis of the data please click here.
I hope this helps clear some of the confusion on what gluten is and what the differences are between classic wheat allergy, celiac disease and gluten sensitivity. As always, you can also follow us on Facebook and Twitter for daily pollen counts, office information, patient education and more. If you enjoyed this post please “Like” us on Facebook.
Dr. Ananth Thyagarajan (Dr. T.)
Eczema affects 10-20% of children and 1-3% of adults. The cause of atopic dermatitis is unknown, but genetic factors play a strong role. The symptoms are secondary to a dysfunctional outer layer of the skin known as the epidermis. Normally, an intact epidermis keeps out environmental irritants, allergens, and microbes. Because the skin is not working properly, these substances get into the body which lead to inflammation. In children with moderate to severe atopic dermatitis, up to 2/3 of them may have some underlying food allergy.
Most people with atopic dermatitis have symptoms before the age of five. Intense itching of the skin, patches of redness, small bumps, and skin flaking are common symptoms. Scratching can lead to additional inflammation, which causes a cycle of itching and scratching that worsen the disease and can potentially lead to decreased sleep and quality of life. In severe exacerbations, the skin may actually start oozing which can be a sign of infection.
There is no specific test to diagnose atopic dermatitis. The diagnosis is based on clinical information like the patient history and physical examination. Testing done by a well-qualified allergist can identify potential triggers like environmental or food allergens.
SKIN CARE, SKIN CARE, SKIN CARE! Appropriate skin care is the cornerstone of treatment for atopic dermatitis. Aggressive moisturizing with a good quality, hypo-allergenic lotion or cream is the key to preventing skin dryness.
The lotion should be applied at least twice a day and within 3 minutes after bathing. Both intermittent and daily bathing are appropriate, but a fragrance free soap and pat-down drying should be used.
Avoiding known triggers can reduce the intensity of atopic dermatitis. Irritants, stress, heat/sweating, infections, and allergens can all cause exacerbations.
Topical steroids or anti-inflammatory creams should be used as needed on red inflamed areas of skin. Only low potency creams should be used on the face because the skin on this part of the body is thin.
Medications like oral anti-histamines can be prescribed to attempt to control itching, but this is controversial.
Treatments like bleach baths and wet wraps can be used in select cases as determined by your physician.
How We Can Help
An allergist can help identify environmental or dietary triggers and work with patients and their families in creating an effective and practical treatment plan. Skin testing to identify these potential triggers should be performed by a trained professional.
Reactions to food are common, and can be divided into two categories, those caused by food allergy and all other reactions. Food allergies develop when the body's immune system has an abnormal reaction to one or more proteins in a food. Food allergies can lead to serious or even life-threatening allergic reactions. Food allergies can be further divided into “classic” and “non-classic” types. Other food reactions are not caused by the immune system. These reactions cause unpleasant symptoms and are far more common than food allergies. Examples include lactose intolerance, heartburn (gastroesophageal reflux), bacterial food poisoning, and sensitivity to caffeine.
In people with "classic" food allergies symptoms typically occurs quickly, within minutes to two hours after eating. The most common symptoms of food allergy include:
Skin: Itching, flushing, hives (urticaria), or swelling (angioedema)
Eyes: Itching, tearing, redness, or swelling of the skin around the eyes
Nose and mouth: Sneezing, runny nose, nasal congestion, swelling of the tongue, or a metallic taste
Lungs and throat: Difficulty getting air in or out, repeated coughing, chest tightness, wheezing, increased mucus production, throat swelling or itching, hoarseness, change in voice, or a sensation of choking
Heart and circulation: Dizziness, weakness, fainting, rapid, slow, or irregular heart rate, or low blood pressure
Digestive system: Nausea, vomiting, abdominal cramps, or diarrhea
Nervous system: Anxiety, confusion, or a sense of impending doom
Some individuals suffer from “non- classic” food allergies. The symptoms of this type of food allergy are usually slower to develop and longer lasting than those of classic food allergies. Symptoms commonly include vomiting, diarrhea, abdominal pain, and/or blood in the stool. Food protein-induced enterocolitis and proctitis/proctocolitis are common types of non-classic food allergy that are seen often in infancy.
A complete and detailed medical history is essential for initiating the proper work up for food allergy. Specific skin and blood testing gives providers added information on determining the likelihood of “classic” food allergy. If a person had a reaction after eating peanuts, but has never reacted to wheat or eggs and eats them regularly, it is not necessary to test for allergy to wheat or eggs. The gold standard test for all food allergy is the oral food challenge, where the food is ingested by the patient in a controlled setting (clinic or hospital) to monitor for reaction. It is important to note that neither the size of the skin prick test nor the level on blood tests translate into severity of allergy. These tests only speak to the likelihood of any reaction.
Once a food allergy is certain, the best treatment is to avoid the food. Patients must carefully check ingredient labels for all food products. The most important aspect of the treatment plan is to have emergency medications available at all times in case of an allergic reaction. In the case of a severe allergic reaction, timely administration of self-injectable adrenaline is the cornerstone of treatment.
How We Can Help
Your Allergy Partners board-certified provider can assist in determining whether or not a food allergy exists, what type of food allergy it is, and what treatment plan is appropriate. Your allergist will help you understand the potential testing options as well as directing you to helpful resources like special food allergy cookbooks, patient support groups, and registered dieticians.
Most cases of hives last only a short time and are triggered by allergic reactions, medications, or viral infections. Allergic reactions are possible to foods, bee stings, medications, or airborne substances. Hives can also be part of a severe, whole-body allergic reaction called anaphylaxis.
In some people, the skin mast cells can react and cause hives due to pressure, cold, heat, vibration, and exposure to the sun or water. Dermatographism (Latin for skin writing) refers to hives that pop up for only minutes after a scratch or irritation to the skin.
It is also possible to have hives lasting for weeks or months. This (chronic urticaria) is usually not due to a particular trigger, but instead it can result from abnormal immune reactions involving the mast cell. The severity of chronic hives can be affected by factors such as stress, medications, temperature, and illnesses.
It is important to identify the cause of hives if possible, and the first step is a careful interview and physical exam with an experienced medical professional. Episodes of hives due to foods, bee stings, medications, or allergens can often be sorted out with allergy testing. A simple cause is not often found for chronic urticaria, but laboratory testing can help sort out any source of inflammation or infection that could lead to long-lasting hives.
Once the cause is determined, it is important to avoid the cause of your hives if possible. Hives usually respond to medications that block histamine -- the major chemical released by the mast cell. These â€œantihistaminesâ€ include the commonly used diphenhydramine (Benadryl®), but mild or ongoing cases of hives can also respond to longer-lasting and less sedating antihistamines, such as loratadine (Claritin®), cetirizine (Zyrtec®), or fexofenadine (Allegra®).
Under the care of an allergist, severe or persistent cases of urticaria can be treated with high dose antihistamines, the addition of other histamine blockers (ranitidine or similar drugs), or the temporary use of corticosteroids (such as prednisone). In severe cases of chronic urticaria, is it sometimes necessary to use other drugs that act on the immune system.
The physicians at Allergy Partners are experts in evaluating and treating the many possible causes of hives and allergic reactions. The evaluation begins with a careful interview and physical examination, followed by any necessary tests. These may include skin testing, which can be done during the initial visit if the patient is not taking antihistamines. For more information on Urticaria and skin testing, please visit our Patient Education page on our website or contact our office.
All Allergy Partners’ physicians are board-certified allergists who have years of training and experience in the treatment of allergies and asthma. Working together, our physicians are able to combine their expertise to ensure that each and every patient receives the very best care. Our physicians are dedicated to identifying clinical best practices that will ensure the very best outcomes for each patient. Such collaboration produces what we like to call the Allergy Partners Difference.
One example of the Allergy Partners Difference is our state-of-the-art allergen immunotherapy program and extract lab. To ensure that immunotherapy is as safe and effective as possible, it is imperative that the extract be made with the highest quality raw materials, that the dosage be optimized to ensure effectiveness and safety, and that the extract be individualized for the patient. Working with national organizations and extract manufacturers, Allergy Partners has developed a state-of-the-art immunotherapy program. Our centralized extract lab, located in Asheville, North Carolina, produces the highest quality allergen extract possible. Abiding by national immunotherapy standards, all Allergy Partners extract is designed to provide each patient an individualized vaccine that will provide the utmost clinical effectiveness while maintaining patient safety.
Allergy Partners is also committed to using the latest technology to improve patient outcomes. Allergy Partners has adopted electronic health records to improve patient safety and communication with referring physicians. All Allergy Partners physicians also employ a secure internal e-mail system that allows them to virtually discuss difficult cases with the entire group of allergists. This affords the patient with access to not just his or her allergist, but a network of over 60 board-certified allergists to help solve the problem.
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We invite you to learn more about Allergy Partners, the conditions we treat, and the services we provide by browsing our website, visiting our social media pages or contacting the practice. Check back often for new updates and the latest information!