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DUKE MEDICINE

Reply: Confused adn Spending Too Much Money and Time

Dear Reddith, Your case brings up some inconsistencies and I would suggest...

Posted by Michael H Land, MD

Dear Reddith,
Your case brings up some inconsistencies and I would suggest getting a second opinion from a board certified allergy specialist, or re-addressing the diagnosis with your current doctor.

Firstly, if the true diagnosis is Non-allergic rhinitis, it might be questionable to treat this with oral antihistamines. Some allergists would treat non-allergic rhinitis with saline lavage, antihistamine nasal sprays, steroid nasal sprays, or anticholinergic nasal sprays. I would suggest asking your immunologist/allergist if an alternative medication that is less drowsy may be used since you cannot tolerate the current regimen.

Secondly, the serum tests for specific IgE do have a lower limit of detection (typically <0.35) which means that it is possible to have a level of 0.34 that is clinically significant. It would show up as undetectable on the result, but that does not necessarily mean "negative."

Regardless of whether skin tests and serum IGE levels agree or do not agree, it is also important to consider what happens clinically. If you are around cats, touch them, hug them, hold them, etc, what happens to you? If you get itchy eyes, runny nose, sneezing, etc, then the skin tests are most likely true.

Tests are useful tools for allergists to use, But we must always interpret them in the clinical context of the patient. For instance, if you told me that you had nasal congestion all winter long from October through February, and skin testing revealed that you were only allergic to Grass pollen, I would probably say that something else is going on (like winter time viral illnesses). The season of grass pollen exposure is in the summer, not in the winter, and just going by the testing is not enough. It could be a trigger for summertime symptoms, but the important part of the evaluation is combining the history with the test results to come up with the diagnosis.

Some folks may have a low level of antibody but it has stronger binding and may be clinically relevant. The difference between a skin test and a blood test is that the skin test is a functional test. It suggests that the allergen is identified by the antibody, which induces mast cell release of histamine and other mediators which then leads to a large skin hive, itching, and redness. The blood test only demonstrates if there is presence of antibody or not.

Another confounding issue is that you might have a very sensitive skin condition called dermographism or dermatographism, which may make skin test interpretation difficult. This could result in false positive skin tests when in reality the allergy doesn't exist.

Bottom line is, I would make sure that you discuss your diagnosis again (make sure that the doctor feels comfortable with the diagnosis in the first place because this determines the treatment) and also your treatment failure (that you cannot tolerate the current medications) to find another medication that you can tolerate.

Good Luck!
MLView Thread

Posted byMichael H Land, MD

1 Reply | Reply | Watch This DiscussionReport This| Share this:Confused adn Spending Too Much Money and Time Dear Reddith, Your case brings up some inconsistencies and I would suggest...

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Reply: Can't drink milk/protein shakes but can eat ice cr...

Dear KimberlyKK, For further reading, I addressed the issue of "testing for...

Posted by Michael H Land, MD

Dear KimberlyKK,

For further reading, I addressed the issue of "testing for food allergies" in an entry about 9 months ago in the link HERE

In this forum (above), I basically say that these tests to detect food specific IgE levels in the blood and skin tests do NOT make a diagnosis of food allergy alone. They Must be carefully interpreted in the right context of clinical symptoms that fit an immune system mediated reaction to be applicable. This is an issue I am very passionate about in my clinic, if you can't tell already. Patients often come to me saying that they "tested positive for XYZ food" but they eat that food just fine or develop other symptoms that are not allergy symptoms.

If you drank coffee and then within 30 minutes, felt sweaty, jittery, and your heart was racing, would you believe you had an allergy to coffee? What if you had a "positive test" to coffee? We all know that these symptoms are a side effect of caffeine. It would not matter what the test showed, because the mechanism behind the symptoms is not an allergic reaction.

What the blood tests look for are antibodies (IgE) that your immune system has made against a food or substance. The significance of this antibody is to initiate an allergic reaction. We may make these antibodies to many substances (and it would be detectable on a test), but they don't cause us to have reactions. This could be misinterpreted as a positive test when in reality it has no clinical significance.

For example, if you "tested positive for prunes" but you were able to eat prunes a few times a day and intermittently developed diarrhea after eating the prunes, then the results of the test are meaningless. I would make a diagnosis of a normal food adverse effect, not a food allergy. However, if you had the same exact test result, but said that you developed lip swelling, hives, vomited, and had wheezing a few minutes after you ate the food each time, the same exact result would be very important and likely to confirm a food allergy.

Far too often, I am seeing food allergies over-diagnosed based on improper interpretation of test results. I would encourage you to discuss this carefully with a board certified allergist to come up with a plan to objectively assess your symptoms and come up with a solid diagnosis, which is what you deserve.

What you describe above sounds like it could be a food intolerance (i.e. lactose intolerance). I hope this helps.
Good luck,
MLView Thread

Posted byMichael H Land, MD

6 Replies | Reply | Watch This DiscussionReport This| Share this:Can't drink milk/protein shakes but can eat ice cream, cheese, and other dairy? Dear KimberlyKK, For further reading, I addressed the issue of "testing for...

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Reply: Severe Eczema?

Dear An_244871, Your photos definitely indicate that you are suffering greatly...

Posted by Michael H Land, MD

1 Reply | Reply | Watch This DiscussionReport This| Share this:Severe Eczema? Dear An_244871, Your photos definitely indicate that you are suffering greatly...

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Reply: itching of the body, mostly upper body (severe)

Dear Anasilva63, Thank you for your direct question. Unfortunately, without...

Posted by Michael H Land, MD

1 Reply | Reply | Watch This DiscussionReport This| Share this:itching of the body, mostly upper body (severe) Dear Anasilva63, Thank you for your direct question. Unfortunately, without...

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Reply: cat allergies

Yes, this is possible, but it really depends on the amount of exposure he has...

Posted by Michael H Land, MD

1 Reply | Reply | Watch This DiscussionReport This| Share this:cat allergies Yes, this is possible, but it really depends on the amount of exposure he has...

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Reply: Relief from chronic hives--finally!

Dear Beachcroft, Thanks for your comments. You describe a condition called...

Posted by Michael H Land, MD

1 Reply | ReplyReport This| Share this:Relief from chronic hives--finally! Dear Beachcroft, Thanks for your comments. You describe a condition called...

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Reply: Allergy to Cold tempertures

Dear Mom_of_4_78, It is possible that your son could have a type of physical...

Posted by Michael H Land, MD

2 Replies | Reply | Watch This DiscussionReport This| Share this:Allergy to Cold tempertures Dear Mom_of_4_78, It is possible that your son could have a type of physical...

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Reply: I think i have an allergic reaction to pain killer...

Dear DanBick, It sounds like you may have two separate problems: firstly, a...

Posted by Michael H Land, MD

1 Reply | Reply | Watch This DiscussionReport This| Share this:I think i have an allergic reaction to pain killers Dear DanBick, It sounds like you may have two separate problems: firstly, a...

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Reply: Finding an Immunologist

Dear Figueroa2011 I'm sorry, but I cannot make a diagnosis or recommend...

Posted by Michael H Land, MD

3 Replies | Reply | Watch This DiscussionReport This| Share this:Finding an Immunologist Dear Figueroa2011 I'm sorry, but I cannot make a diagnosis or recommend...

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Reply: Water allergy

Dear An_241541, The short answer is, NO, you cannot be allergic to water. Water...

Posted by Michael H Land, MD

3 Replies | Reply | Watch This DiscussionReport This| Share this:Water allergy Dear An_241541, The short answer is, NO, you cannot be allergic to water. Water...

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