All posts by Stephen J. Klemawesch, MD

Allergy ties to additives studied

The University of Maryland recently published data about increased incidence of allergy in children correlating with the amount of residues of triclosan and paraben found in their urine.

Triclosan is a chemical that has been added to many personal care and medical products, including soap and toothpaste. It is added for its antimicrobial properties. Paraben is added to food, pharmaceuticals and personal care products, also for its antimicrobial properties.

Both have been previously shown to have immune-modulating properties (in addition to their antimicrobial property). In this particular study there was a strong relationship between urinary levels of these chemicals and the development of a variety of allergies: asthma, eczema and food allergy.

The unstated — but implied – recommendation is to limit childhood exposure to these chemicals

Promising asthma drug in pipeline

A research study of a new drug given to steroid-dependent asthmatics has produced exciting results.

Reported in a recent article in The New England Journal of Medicine, the new asthma drug, Mepolizamab, was tested at various medical centers around the globe, including the University of Pittsburgh.

Mepolizamab is a humanized monoclonal antibody that inactivates interleukin– 5. Interleukin– 5 is a cell communicator that recruits eosinophils (allergic cells) into the lungs.

The eosinophil is a form of white blood cell that causes airway inflammation — asthma’s hallmark.

The remarkable outcome of this study revealed the participants enjoying a marked reduction or cessation of steroid medication, while having improvement in their asthma, along with fewer flare-ups.

The drug was administered by injection once a month and was relatively free of side effects. The main ones were headache and sore throat.

The drug has not finished all its clinical trials for FDA approval, but it should soon. For now the only other monoclonal asthma therapy is Xolair, which binds to the allergic antibody IgE.

Dear Doc: Explain sprue/celiac disease immune reactions

Dear Dr. K: My gastroenterologist said that my blood pressure pill, Benicar, caused me to develop sprue. Can this be true?

To answer your question in a broad sense: “Yes;” but in a strict sense, “No.”

To better understand this yes/no scenario a few definitions would be helpful.

Sprue (also known as celiac disease) is a form of GI upset with diarrhea caused by an immune reaction to gluten. The immune reaction leads to inflammation in the intestinal wall, with resultant atrophy of the villi.

The villi are critical for properly digesting food (due to enzymes found on the villi), and for properly absorbing food (due to increasing absorptive surface area).

Benicar (Olmesartan) is one of a family of anti-hypertensives known as angiotensin receptor blockers. It has been implicated in a number of cases of chronic diarrhea, with biopsies that show villous atrophy.

However, unlike in sprue, there is no inflammation and also unlike in sprue, the illness does not improve with avoiding gluten. It does however, improve with going off the Benicar which allows the villi to regrow.

The Mayo Clinic has had a keen interest in this issue, and has even found some patients on Benicar with mild villous atrophy, but no symptoms.

What is reassuring about this research is that treatable conditions are being discovered for a large group of individuals previously labeled with “IBS” (Irritable bowel syndrome). The term syndrome means no known cause, but does not imply a cause can’t be found.

Even tiny whiff enough to trigger allergic reaction

A review of food reactions in children from inhalation was recently published in an issue of Allergy and Asthma Proceedings.

As an introduction, the authors remind readers we are able to smell foods because of tiny aerosolized particles of food. In some children, even this tiny amount of exposure can lead to allergic symptoms.

The foods most commonly implicated in this mischief are: fish, nuts, legumes, grains and cow milk.

Up to 10 percent of children allergic to fish will have some type of allergic response to seafood odors or fumes. Typically, this is eye itching, sneezing or wheezing.

Of interest, shellfish were much less likely to cause inhalation problems than “swimming” fish.

The incidence of airborne nut allergy was smaller with three percent of children with tree nut allergy reacting to the smell, and one percent of peanut-allergic children reacting. (Even though peanut is a legume, it was studied in the nut category because there are so many children with peanut allergy.)

Again, common symptoms seen were eye itch, sneezing and wheezing. But some children suffer hives and even anaphylaxis from nut odor inhalation.

The most common legumes to cause inhalation allergy are soy, chick peas, peanut-like lupines and green beans. The spectrum of symptoms: eye itch, sneezing and wheezing, but also intense itching in the mouth and throat in some children.

The cereal grains most likely to cause problems are rice, buckwheat and wheat. Buckwheat is more common a cause than expected because many children have ongoing exposure from buckwheat chaff being used in stuffed animals.

And while cow milk is a common cause for inhalation allergy, some children are sensitized from powdered formulas being mixed in their presence.

Also, as mentioned in a previous newsletter, some asthma inhalers contain small amounts of milk protein as a stabilizer.

Many ways for mold to catch hold

The Tampa Bay Times recently featured an article detailing the closure of a city building due to mold contamination. The Madeira Beach building was more than 60 years old and had been flooded several times over the years.

The message here is that any Florida building can have unhealthy mold issues.

The most common causes are water incursion, and heating and cooling system (HVAC) issues. Water incursion can be due to flooding, broken pipes and roof leaks. HVAC issues include leaks in the air handler/duct system and compressor/air handler mismatch. The latter situation occurs when the BTU capacity of the compressor is too high for the system. This leads to rapid cooling of the air before it can be adequately dehumidified, with resulting moist, cool air leading to mold growth in the system.

One good resource to investigate possible indoor mold issues is via the environmental specialist at the Pinellas County Health Department.

Q-Tips: Streptomycin Allergy

  • The recent Annals of Allergy published an article about a 10-year-old girl who suffered anaphylaxis from antibiotic residue on blueberries. The child was not known to be allergic to blueberries and later tests proved this fact. The blueberry orchard was treated with streptomycin and the child did show a positive allergy test to this antibiotic.

Dear Doc: Can allergy be blamed for loss of smell?

Dear Dr. K: I’ve lost my sense of smell. Could this be due to allergy?

The answer to your question is, yes, it could be, but it is unlikely. I say that because on your recent visit here your allergies were under excellent control and the only time I’ve seen anosmia (loss of sense of smell) from allergy is when it is severely out of control.

A complication of allergy that frequently causes anosmia is nasal polyposis. Treatments of the polyps via nasal sprays and/or surgery usually returns the sense of olfaction (smell).

Placebo effects have a cousin: Nocebo

The American Journal of Medicine had a recent review article titled, “Placebo: The Good, the Bad, and the Ugly.”

Placebo effect is defined as any improvement in discomfort or illness resulting from an intervention possessing no physical effect. Historically, the best research techniques always include a placebo control group and double-blinding — that is, neither the researchers nor the study patients know which group is which until the study is completed. Interestingly, surgery and physical manipulation of the body, such as physical therapy and chiropractic, have greater placebo benefit than oral medication.

Such properly conducted research has led to the realization that there also exists a “nocebo” effect, which is symptoms or illness resulting from expectations or fears of a bad effect. (Kind of like reading a list of possible adverse side effects from a medicine and thinking you are experiencing some of the symptoms.)

Both the placebo and nocebo effects can occur as a “take-away” from the benefit of a traditional therapy, or can stand alone from an inert therapy.

The nocebo effect also is why all drug trials demonstrate significant rates of undesirable side effects in the control group. These negative reactions are felt to come from the individuals’ innate pessimism or tendency toward depression.

Azithromycin helps prevent COPD set-back episodes

A study outlining the use of weekly azithromycin for COPD patients with frequent exacerbations was published recently in the world’s leading general medical journal, Lancet. “Frequent” was defined as three or more episodes in a year of these episodes of sustained worsening of these patients’ conditions.

Several cogent reasons warrant attempting to prevent these exacerbations. First and foremost, they make the patient sick and can lead to hospitalization, and sometimes to death. Also, each exacerbation can worsen the overall degree of lung impairment, kind of a racheting down in lung function. The patients in the year-long Lancet study were treated with 500 mg. a day of azithromycin for the first three days of each week.

This particular drug was chosen because it has immunomodulatory properties. That is, it works not only as an antimicrobial, but also as an anti-inflammatory. It is concentrated 200 times in the white blood cells, which go to the bronchial tissues. It also has a long half-life of about 70 hours after a dose.

Patients in the trial had 58 percent fewer exacerbations.  Additionally, this benefit lasted for more than six months after the drug was stopped.