“Dr Schreiber, We have a 25 year old female inbound by EMS with hives, shortness of breath, and hypotension. They will be here in two minutes. Do you have any orders for the paramedic prior to arrival?”
“Start two IV’s and run fluids in wide open. Start supplemental oxygen. We will be waiting in trauma two.”

As the patient was hustled down the corridor to trauma two, I listened to the paramedic tell the ER Nurse the history. “She is 25 years old with a history of being allergic to red dye. She was eating at a restaurant and ordered cheese soup after confirming with the waiter that it did not contain red dye. Within minutes of eating the soup she started feeling funny and asked the waiter to call 911.Currently her vitals are: heart rate 125 beats per minute, blood pressure 70 over palpable, respiration 80 per minute with an oxygen saturation of 90% on room air. She is covered in hives form head to toe, semi alert due to her low blood pressure and in extreme respiratory distress.”

As the paramedics and ER nurses were transferring the patient from the gurney to the emergency room bed, I reached into the crash cart and grabbed a dose of Epinephrine 1:1000, drew up .3 cc and injected the patient with the Epi. I massaged the shot site to increase the speed of uptake while I ordered IV steroids and Benadryl. I also prepared to intubate the patient to safeguard her airway.

In less than one minute I witnessed my first medical miracle. Her hives started to fade, she went from panting at 80 breaths per minute to taking a deep breath, sighing and then she looked up at me and said “Thank you!”

I was told in pharmacology that Epinephrine worked quickly, but this was magic! From dying to thank you in 60 seconds! Wow! She did well and was released from the ER after 23 hours of observation.
These events happened in 1989 at Bexar county hospital in San Antonio, Texas when I was an Internal Medicine Intern. This was my very first exposure to anaphylaxis.

Anaphylaxis is one of the most terrifying experiences a person can have. One can transform from perfectly healthy, to near death, in a matter of moments after exposure to something they have been sensitized to. Common triggers are insect stings, medications and certain foods.

What shocked me most was how little the faculty and staff in the ER knew about anaphylaxis. They knew how to treat anaphylaxis acutely to save the patients life, but not how to prevent the next episode from occurring. This is one of the incidents that piqued my interest in allergy as a career.

After two years of internal medicine residency I knew I did not want to practice internal medicine for the next thirty years. During my third year of residency I took two immunology based electives; Rheumatology and Allergy. My impression of Rheumatology was that it was more about managing chronic pain than it was about immunology. My interest in Rheumatology quickly faded. During the first week of my allergy elective I knew I had found my specialty. Convincing my wife that she and our children would have to endure two more years of my training was not all that easy. She was tired of poverty, but nonetheless supported me like a trooper. After residency I took a two year fellowship in Allergy at UTMB in Galveston. I have never regretted my decision, as I have never found anything more rewarding than improving the quality of life of an allergic or asthmatic patient.

Allergic rhinitis can either be seasonal or perennial.

Seasonal rhinitis is due to the presence of plant pollens in the outdoor air.  The plants in bloom are responsible for the pollen and symptoms it causes.  The predominant seasonal antigens are three pollen (February – April), grass pollen (April – August), and wee pollen (September – October).  Flowers are usually not the culprits because they are pollinated by insects such as bees.

Perennial rhinitis is caused by allergens that are present in the air year round.  Examples of such allergens are dust mites, molds, animal dander and, in the years with no freezing winter temperatures, grass pollens.

Typical symptoms of allergic rhinitis include itchy watery eyes, sneezing, runny nose, nasal itching, congestion, post nasal drip, headaches, dry cough, ear fullness and ringing, decreased sense of smell, taste and fatigue.  Many people feel their symptoms are due to “sinus problems” or a “cold”.  Sinus infections and colds tend to be associated with fever and yellow to green mucous whereas allergic rhinitis is associated with clear mucous and tends to occur repeatedly throughout the year.  Other findings one might see are dark circles under the eyes called allergic shiners, and a crease across the top of the nose due to chronic nasal rubbing.  People with allergic rhinitis also tend to have bad breath due to the postnasal drip.  Common complications due to untreated allergic rhinitis include sinusitis, nasal polyps, and otitis media.

Allergic rhinitis responds to medical treatment and allergy shots.  The medications commonly used include antihistamines, decongestants, and steroid sprays.

Effective means of controlling allergic rhinitis include:

• Avoidance of allergens
• Medications
• Allergy shots

Allergic diseases occur in people who are genetically predisposed and have had prior exposure to an environmental antigen.  Antigens, or allergens, are usually protein molecules that are produced by plants or animals.  Common allergens include pet dander, plant pollens, insect droppings and insect venom.  Antigen exposure in genetically predisposed people, results in sensitization and eventually allergic symptoms.  Allergic symptoms include nasal congestion, sneezing, runny nose, itchy watery eyes, chest tightness, wheezing and shortness of breath, skin rashes and gastrointestinal complaints.  Food allergies are more common in children and can be severe.  Symptoms of food allergy can be as mild as nausea, vomiting, diarrhea and skin rashes or as severe as asthma and anaphylactic shock.

Most allergies individuals have family members who also have allergies.  If one parent has allergies, each child has a fifty percent chance of having allergies.  If both parents have allergies, each child has a seventy five percent chance of having allergies.  Children who develop skin problems (Eczema) at an early age are at a higher risk of developing allergic rhinitis and asthma as they grow up.  Early diagnosis and treatment can prevent development of asthma in children.  Allergy symptoms, and some of the medications used to treat allergies, can impair a child’s performance in school and an adult’s performance at work.

People who have developed sensitivities to environmental antigens (such as weed pollen, cat, dust mite, etc.) will have allergic reactions when they are exposed.  Reactions start within minutes of exposure and will continue until you treat the symptoms and avoid the causative antigen.  Allergic reactions have two phases, the first starting with the mast cells in your body releasing histamine.  Histamine dilates the blood vessels.  Dilating the blood vessels allows fluid to leak out of the blood into the tissue.  Leakage of fluid into the tissues causes swelling and increased mucous production in mucous membranes.

The second phase is triggered by histamine and other mediators recruiting inflammatory cells (T cells and others) into the local area.  Once enough inflammatory cells are present in the local area, these cells begin producing hormone like molecules called cytokines.  Cytokines allow the inflammatory cells to communicate with each other and perpetuate the inflammatory response.  It is this self-perpetuating inflammatory response which is responsible for the inability of antihistamines and decongestants to maintain long term control of allergic symptoms.  Anti-inflammatory medications are necessary to turn off the second phase of the allergic response.

Common allergic diseases are allergic rhinitis, asthma, urticaria, anaphylaxis, allergic eczema, and food allergies.

There are three ways to treat allergic problems: avoidance, medication and immunotherapy.

Avoidance

Avoidance of the things that cause your allergies is a very effective means of alleviating allergy symptoms.  However, this is not always possible.

Implementing environmental control measures can reduce your exposures thereby reducing your symptoms.

Allergic patients who respond well to environmental control are those typically allergic to dust mites, pets and mold.

Medication

There are two general categories of medications; those that relieve symptoms and those that prevent symptoms.  Medications are often available in pill form (systemic) or topical (local).  Systemic medications (pills, syrups or injections) are delivered by the bloodstream to the entire body.

Local medication (nasal sprays, eye drops, inhalers, lotions and creams) are applied directly to the area involved in the allergic reaction.  Generally speaking, local medications have fewer side effects than systemic medication.

Medications that are made to relieve symptoms include antihistamines and decongestants for allergic rhinitis, and bronchodilators (inhalers) for asthmatics.  Preventative medications are the anti-inflammatory steroids (topical and systemic).

Immunotherapy

Immunotherapy is a means of retraining your immune system to no longer react to the things you are allergic to.

The response to immunotherapy varies depending on your age, and the allergens to which you react.  People under the age of twenty years old respond more favorably (80-90% with remarkable improvement).  Individuals over the age of fifty five are less likely to respond (50%).

People who are allergic to dust mite, pet and pollen allergens respond better to immunotherapy than mold allergic individuals.  Food allergies do not respond to immunotherapy.  The only treatment for food allergy is avoidance.