Oral Allergy Syndrome
Delicious, ripe, mouthwatering fruits and vegetables are more plentiful during these summer months. However, that that summer breeze may carry more than just excitement for the season. Some people with environmental allergies may notice that certain fruits, vegetables, or nuts give them distinct allergic symptoms, typically confined to the lips, mouth and throat. This phenomenon is known as oral allergy syndrome (OAS).
Oral Allergy Syndrome
Oral allergy syndrome, or pollen food allergy syndrome, occurs when there is a cross reaction or a confusion in the body. Some fruits, vegetables, and nuts have a similar protein to the allergy-causing protein on the surface of the pollen grain. According to the American Academy of Allergy, Asthma, and Immunology (AAAAI), "These proteins can confuse the immune system and cause an allergic reaction or make existing allergy symptoms worse, which is referred to as cross-reactivity." It is a contact allergic reaction, but it also considered a mild food allergy.
Cross Reactivity
During the summer season, cross reactivity with grass and weed pollen most commonly triggers OAS. Timothy grass, orchard grass, and ragweed pollen tend to cause more reactions. Other grasses and weeds may also contribute to OAS symptoms. People with allergy to timothy grass and orchard grass may experience OAS when consuming foods like peaches, oranges, and tomatoes. Those allergic to ragweed pollen can experience symptoms when eating foods like banana, cucumber, zucchini, and some melons such as honeydew and cantaloupe. Watermelon and white potatoes can trigger a response in both grass and weed pollen sufferers equally.
Symptoms and Treatment
Typically, oral allergy syndrome symptoms present as itching or swelling in the mouth and throat. Symptoms can also be present on the face, lips, or tongue. While the symptoms usually appear immediately after eating raw fruits or vegetables, in rare cases the reaction can occur more than an hour later. Eating the food in the rawest or purest form usually triggers the more severe symptoms. Peeling, cooking, or baking the food can greatly reduce or eliminate a reaction all together.
For most people, the allergy symptoms are localized to their mouth and are uncomfortable or annoying. However, up to 9% of people have reactions that affect a part of their body beyond their mouth. About 1.7% can suffer a life-threatening allergic reaction or anaphylaxis. For this reason, it is crucial for people to determine what might be causing their symptoms with allergy testing and food journals. Avoid eating that allergy-causing food (especially in that foods peak allergy season). It is also beneficial to consider treating the underlying pollen allergy with immunotherapy.
Amanda Hofmann, MPAS, PA-C, is a graduate of Duquesne University, in Pittsburgh, Pennsylvania. After spending eight years in clinical practice, she joined United Allergy Services as the vice president of clinical. Amanda is also the past president of the Association of PAs in Allergy, Asthma, and Immunology.
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Eosinophilic Esophagitis (EoE)
Eosinophilic esophagitis (EoE) is a recognized diagnosis that produces symptoms related to dysfunction of the esophagus. In EoE, large amounts of white blood cells, specifically eosinophils, collect in the inner lining of the esophagus resulting in inflammation. Typically, the esophagus is free from eosinophils and resulting inflammation, and so in EoE, a patient will begin to notice a difference in the way they can eat and swallow food. This condition can be difficult to diagnose as other conditions can present with eosinophils in the esophagus, and historically EoE has not been a common or well-known disease. Awareness has significantly improved however in the last decade, and patients are being recognized and diagnosed much earlier. This week, the FDA has approved the first ever treatment for EoE.
Symptoms of EoE
Many EoE patients also have symptoms of one or more allergic disorders like asthma, allergic rhinitis, atopic dermatitis (eczema) and food allergy. It is important for EoE patients to be properly assessed and tested for potential allergens as well as properly diagnosed for their atopic conditions. Similar to proper diagnosis, it is crucial that any and all allergic aspects of EoE can be properly treated in conjunction with management of the EoE. Patients benefit from a team of providers working together such as a primary care provider, allergy specialist, and gastroenterology specialist.
Early diagnosis of this chronic condition is important so patients can be educated and properly managed, sparing them from discomfort, malnutrition, and even life-threatening situations. An emergent situation can arise if inflammation becomes too great and causes narrowing in the esophagus, trapping swallowed food. In younger children, EoE typically presents with poor feeding, failure to grow properly, vomiting, reflux symptoms, and abdominal pain, whereas in adolescents and adults EoE most often presents with dysphagia (trouble or painful swallowing) and emergent esophageal food impactions.
Allergy Correlation
Airborne allergies can play a role, however adverse immune responses to food are the main cause of EoE in many patients. It can be more difficult to properly diagnose food allergies in EoE patients because many do not present with the typical symptoms associated with IgE mediated food allergy. Instead of immediate itching, flushing, hives and vomiting after ingestion of the offending food, the reactions can be delayed over hours or days. Milk, egg, soy and wheat are recognized as the most common triggers for EoE, however, conventional allergy tests often fail to detect sensitivity to the foods causing EoE. This is because most food allergy reactions in EoE are delayed and caused primarily by immune mechanisms other than classical IgE-mediated food allergy.
Diagnosis
Other than proper identification and diagnosis of atopic conditions, EoE must also be properly diagnosed itself as a disease. If EoE is suspected, a specialist performs an upper endoscopy, where a small tube with embedded camera is passed down the esophagus. The tube not only has a camera and light for inspection, but a small device to take samples, or biopsies of the esophagus. The biopsies of the esophagus are examined under a microscope for eosinophils and inflammation and are necessary to diagnose EoE. A provider looks for appropriate symptoms that were described above, visual inspection of the esophagus, and examination of tissue biopsies to make the final diagnosis of EoE.
Managing EoE
There are many viable options to managing EoE effectively. Food sensitivities or allergies can be managed by removing those offending foods from a person’s diet, but only under the direct guidance and supervision of a provider. A provider can advise eliminating a specific food, or a food group based on individual history, examination, and diagnosis. This elimination approach can be helpful to some, but it is important to only remove what is advised, and a medical provider will closely monitor a person and regularly discuss nutrition and intake. Many times, a dietician is added to the medical care team to make sure a person is still receiving all the necessary nutrients. A provider’s goal is to carefully add back any foods that can in fact be tolerated and are proven not to incite eosinophils in the esophagus.
Aside from adjustments to a person’s diet, there are some medications providers use to help provide symptom relief and management of the EoE. It is important to note that aside from the first medication being approved by the U.S. Food and Drug Administration (FDA) to treat EoE, typical options for treatment include proton pump inhibitors and steroids. Proton pump inhibitors (PPIs) reduce acid production in the stomach and have also been found to be able to reduce esophageal inflammation in some patients with EoE. PPIs are very commonly used as a frontline therapeutic for EoE patients. If PPIs do not work for a patient, another option may be swallowed topical corticosteroids. Swallowing small prescribed doses of corticosteroids so they come in direct contact with and treat the inner lining of the esophagus is the most common treatment.
Amanda Hofmann, MPAS, PA-C, is a graduate of Duquesne University, in Pittsburgh, Pennsylvania. After spending eight years in clinical practice, she joined United Allergy Services as the vice president of clinical. Amanda is also the past president of the Association of PAs in Allergy, Asthma, and Immunology.
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