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Author: Stephen J. Klemawesch, MD

Shitaki ‘shrooms tasty, but linked to streaky, itchy rash

Shitaki ‘shrooms tasty, but linked to streaky, itchy rash

Now, say that fast three times with your mouth full of mushrooms.  Shitake toxicoderma is a very common dermatitis in Asia, especially, China, Japan and Korea.  However, it is being seen more commonly in the U.S. as the popularity of shitake mushrooms increases.  The rash is fairly unique, consisting of a long linear array of urticaria. The skin looks like it has been whipped with cat-o-nine tails having red raised streaks that are very pruritic. The itchy lines can last for several weeks, and typically occur within a day of eating raw or cooked shitake mushrooms.
The mechanism of rash is felt to be due to Lentinam a polysaccharide found in the mushrooms that has immune-modulating effects. In fact, Lentinan has been used for chemotherapy in the treatment of colon and gastric cancers, It seems that individuals who get the rash have a hyper-immune response. Sun exposure can act as an adjunctive factor. The rash can be treated with steroids, usually topically, but if the problem is severe, oral steroids are used.
More reasons to protect with shingles vaccine: Vision-robbing after-effects, even blindness

More reasons to protect with shingles vaccine: Vision-robbing after-effects, even blindness

Since the article in the last issue of Allergic Reaction about Ramsay Hunt Syndrome from shingles, four patients from this office have commented on the much more common problem from shingles. That is eye involvement.  Four individuals either had the complication themselves or knew a relative or friend with the eye involvement. All four of them felt that since the eye issue is so severe, people should know about it so they can protect themselves with the vaccine.
So here are some facts:
The most common complication of shingles (herpes zoster) is post-herpetic neuralgia. This occurs in about 20 percent of people who have shingles and can be a life-long source of recurrent pain in the area where the shingles broke out.
The second most common complication of shingles is herpes zoster opthalmicus (eye involvement), which occurs in about 2.5 to 3 percent of cases of shingles. Types of eye problems include conjunctivitis, iritis, uveitis and keratitis. All of these conditions can lead to varying degrees of loss of vision – including blindness.  In some people the eye condition re-occurs repeatedly, even though the shingles don’t.
Once again, the best prevention for this complication is vaccination.  Of note, when the vaccine was first released, the recommended age was 60 and older.  Because the vaccine has proven to be so safe and so   effective in preventing shingles and its complications, the age recommendation has been shifted to 50 and older.
Mosquito repellant works well, but…

Mosquito repellant works well, but…

The frequent rains this summer have led to a bumper crop of hungry mosquitoes. Although many repellants are available, the most effective compound seems to be DEET. It works because its scent is extremely irritating to biting insects, such as mosquitoes and fleas.  Unfortunately, DEET is fairly allergenic with upwards of 30 percent of individuals developing a rash after repeated use. The types of rash seen are contact dermatitis (looks like poison ivy), eczema and urticaria (hives). The fact that DEET is a somewhat irritating chemical, and that it is repeatedly applied to the same skin areas, leads to the development of allergy.
Luckily, a new effective repellant has recently been developed – picordin. It, too, works because its scent dissuades biting insects; however, unlike DEET, it is not irritating or allergenic to the skin. Also, it is tolerated even in individuals already allergic to DEET.
Peanut allergy vaccine – mixed opinions

Peanut allergy vaccine – mixed opinions

Dear Dr. K: Please give us an update on the vaccine for peanut allergy.
Your request is very timely as I recently finished reading a pro/con editorial in the journal Asthma and Allergy Proceedings. I think these two editorial viewpoints sum things up quite nicely.  The first of the two is titled, “Oral and Sublingual Peanut Immunotherapy Is Not Ready for General Use.” In this article written by the director of allergy at the University of Michigan, the focus in on the high frequency of patients who experience symptoms from the oral vaccine – including anaphylaxis – which required use of epinephrine.
Analyzing five recently published trials on peanut vaccine revealed that in each study, more than one half of patients had some type of reaction as the vaccine was built up. The reactions led to some parents removing their children from the study. In the five protocols reviewed the drop-out rate varied from 5 to 25 percent.
The author points out that the vaccine works by two mechanisms: tolerance and desensitization. Tolerance occurs by depleting the allergic antibody (IgE) to peanut. To maintain the depletion, the vaccine must be continued daily. If the vaccine is stopped, tolerance also stops because IgE rebuilds itself.
Desensitization is what occurs with traditional allergy shots. It leads to an increase in protective IgG against peanut (called blocking antibody), and a decrease in IgE. This type of protection is more desirable and can persist even after the vaccine is stopped.  The author points out that even though the vaccines do seem to elicit both modes of protection, no long-term study has been done to show how long-lasting the benefit is. Therefore, the author concludes that for now, the vaccine should be restricted to research protocols until the risk/benefit ratio is better understood and the long-term benefit is fully determined.  The contrasting editorial is from the Paul Foster School of Medicine in El Paso, Texas, and is titled,  “Oral Immunotherapy for Peanut Allergy in a Clinical Practice is Ready.” This author argues that the annual rate for accidental peanut ingestion is 10 percent which leads to severe symptoms, including anaphylaxis and the need for epinephrine.  This number far exceeds the number of vaccine-induced reactions requiring epinephrine. He further argues that peanut allergy has a major effect on the quality of life of the patient and his/her family, and can be psychosocially debilitating. Also, unlike other food allergies where remission is high, less than 20 percent of peanut allergic children have spontaneous remission.  Finally, he cites the outcome of three clinical trials done in office-based settings that treated a total of 150 children. Of these, 111 were successfully able to take the vaccine and were protected in a purposeful challenge of eight peanuts.
Meningitis a threat to those with defective or missing spleen

Meningitis a threat to those with defective or missing spleen

Spleenectomy (surgical removal of the spleen), or functional asplenia, is a significant risk factor for meningitis. And curiously, the most common bacteria to cause meningitis in these patients is the germ pneumoccus (most commonly associated with bronchitis and pneumonia).  Patients with splenic dysfunction lose an important site of both antibody production and immune cell production. They also can no longer filter blood-borne bacteria; hence, a germ that normally causes a respiratory infection can get into the bloodstream and land in the brain.
In the general public, pneumoccus accounts for 70 percent of the cases of meningitis, and is even a more common cause in people with dysfunctional spleens.  The most common reason for surgical removal of the spleen is because it ruptured from blunt trauma, such as in sports injuries or motor vehicle accidents. The most common causes for functional asplenia are congenital hyposplenism, sickle cell disease, celiac disease, bone marrow transplant, HIV infection, liver cirrhosis and lymphoma.  Luckily there is an excellent way to prevent this meningitis risk and that is to take the pneumovax, also known as PPV-23 (23-valent polysaccharide pneumococcal) vaccine.
One caveat though, is to be sure to measure post-vaccine antibodies. Because the spleen isn’t functional, there is a chance that a single vaccine may not be fully effective. By measuring the antibody levels after vaccination, a determination can be made if a booster is needed.
Q – Tips; Auvi-Q epinephrine injector

Q – Tips; Auvi-Q epinephrine injector

• Auvi-Q is a new, user-friendly epinephrine injector. The auto-injector device has an audio message that verbally walks the patient through administration of the drug. This audio-prompter is built in to the injector as a single unit. This new device has proven useful in patients who otherwise are hesitant to use epinephrine.
Q – Tips; sleep deprivation and vaccines

Q – Tips; sleep deprivation and vaccines

• Sleep deprivation can lessen the immune response to vaccines, report researchers at UCLA. In a controlled study they found that restricting sleep to four hours per night for five days led to only a 50 percent response to vaccination. Take-home message: If your or your child are sleep-deprived put off getting your childhood or adult vaccines until you are well-rested.
Chronic Pruritis

Chronic Pruritis

A recent issue of the New England Journal of Medicine contained an excellent review article on the condition known as chronic pruritis – defined as an itch (either localized or generalized) that lasts longer than six weeks. The problem is more common in women than in men and more common in Asians than other races.
The authors of the review article point out that chronic itch can be as debilitating as chronic pain,
leading to changes in sleep patterns and mood disturbances including anxiety and depression.
The sense of itch is carried on unmyelinated C fibers which overlap with the fibers carrying pain.  Over-stimulation of the brain areas receiving these nerves can lead the brain to overreact to noxious stimuli that would otherwise normally inhibit itch, such as scratching or heat/cold exposure. This brain overreaction can also lead to curious symptoms, such as having intense itching associated with undressing.
There are four primary sources of chronic pruritis:
1. Inflammatory skin conditions
2. Systemic diseases
3. Neuropathic disorders. Believe it or not, these can’t be distinguished by the presence or absence of rash because most individuals with chronic pruritis end up with a rash due to trauma to the skin from scratching.
4. Psychiatric conditions.
The most common skin conditions leading to chronic itch are eczema, psoriasis, dry skin, scabies, contact dermatitis, Lichen planus and insect bites. These are best diagnosed by the patient’s history, the appearance of the skin and perhaps, with a skin biopsy.
The most common systemic diseases to cause itch are chronic kidney disease, liver disease, Hodgkins disease, polycythemia, HIV infection and hyperthyroidism. These conditions are best identified by the patient’s history, examination and lab evaluation.
The most common neuropathic causes are brachioradial pruritis (previously discussed in this newsletter), notalgia parasthetica and post-herpetic itch. In all these cases there is a peripheral nerve that is injured or irritated, leading to the itch signal being sent to the brain.
The most common psychogenic causes are OCD (obsessive compulsive disorder), delusions of parasitosis and substance abuse.
Obviously, the treatment is going to vary greatly depending on the cause of the itch. However, even with an accurate diagnosis the itch may be resistant to treatment. In most cases, keeping the skin moist and hydrated is helpful.
Since the C-Fibers are histamine-activated nerves, the use of sedating antihistamines is also helpful. Because of the brain over-stimulation scenario, anticonvulsants and antidepressants have also proven useful.
Finally, because of the overlap of itch and pain fibers, mu-opiod antagonists have often been of help.
Ramsay Hunt Syndrome and chicken pox

Ramsay Hunt Syndrome and chicken pox

Dear Dr. K:  My aunt has Ramsay Hunt syndrome and her doctor said it was a second bout of chicken pox.  Is that true?
The answer to your question is yes and no. In the strictest sense the answer is no, because your aunt doesn’t have generalized chicken pox, but rather a very localized rash. The answer is  yes because, in general terms, Ramsay Hunt is a special form of shingles which is a reactivation of the dormant chicken pox virus (Varicella zoster).
Shingles gets its name because the Varicella virus breaks out in the distribution or dermatone of a single nerve affecting a localized “shingle” of our skin covering.
Ramsay Hunt is an interesting condition because it has unusual neurologic symptoms, in addition to the typical blistering rash. Typically, the patient’s first symptom is severe unilateral ear pain (before any rash). Other common symptoms include facial weakness or paralysis on the side of the ear pain, and ear problems including tinnitus, hearing loss and vertigo.
The shingles rash appears on the ear pinna, the side of the face and side of the neck under the ear.
This condition is preventable with the Zostavax (shingles) vaccine, and can be treated with an oral antiviral and corticosteroids. The earlier this therapy is started, the better.
So, thanks for your question as it may lead to greater awareness of this very unpleasant condition – and to more early diagnoses.
Narcolepsy

Narcolepsy

Recent research has discovered that narcolepsy is a genetically controlled autoimmune disease. Individuals with the gene HLA-DRz/DQI have a very high risk that their immune system will attack a
part of the brain called the hypothalamus. It is in this brain region that an important neuropeptide called hypocretin is made.
Hypocretin is a very important neuropeptide for maintaining alert wakefulness. If the cells in the
hypothalamus that produce it are damaged or destroyed, narcolepsy occurs.
This condition is characterized by a tendency to fall asleep inappropriately during the day. Other unusual symptoms can also occur, such as cataplexy (sudden loss of muscle tone); sleep paralysis (awakening to find your body paralyzed except for breathing); hypnogogic hallucinations (seeing hallucinations just as you’re falling asleep), and what may seem like absent-minded behaviors (such as driving past your exit on the interstate or putting clothing in the refrigerator).
The lack of alerting effects of hypocretin allow non-REM sleep and/or REM sleep to intrude into wakeful times; hence, the unusual symptoms.
Treating this condition can be very helpful but – as in all medical illnesses – it requires an accurate diagnosis. This is probably best accomplished by a sleep doctor. Unlike sleep apnea, it doesn’t respond to CPAP treatment. The two main treatments are daytime stimulants and methylphenidate, and REMsuppressants such as protriptyline.