Dr. Vivek Kumar

Month: May 2020

  • Allergen avoidance strategies

    Allergen avoidance strategies

    House dust mite:

    • Wash your bedsheets, pillow covers, and other covers used on bed at 55-60 degree C every 1-2 week
    • Order dust-mite proof bedsheets online or get it stitched from your local tailor of impermeable material
    • Avoid moisture collection in your room: allow sun light over bed, allow cross-ventilation in bed room. Try to maintain relative humidity <50%.
    • Use HEPA filter fitted vacuum cleaners only.
    • Avoid using carpets as they are difficult to get rid of dust completely.
    • Clean the curtains, mosquito nets, and other items which can collect dust easily, reduce their use, or avoid completely wherever possible.
    • Soft toys like teddy bear are known to attract dust mites, wash them at 55-60 degree C or keep them in freezer compartment to kill the dust mites.

    Pollens:

    • Know your pollen it’s pollination calendar, whether perennial or seasonal.
    • Limit your outdoor time during pollination season.
    • Track pollen calendar where feasible/possible- consult your allergist.
    • Wear full covering goggles to prevent pollens from entering your eyes.
    • Wear face mask meant to reduce pollen entry in your breath, see the label/description which comes with face mask.
    • Clean your AC filter weekly
    • Don’t dry your cloths outdoor during pollination season, instead use a cloth dryer.
    • Take a shower, wash your hairs after coming from outside.
    • You have to be extra careful during pollination season of the pollen you are allergic to.

    Cockroach:

    • You and your family members should eat at the place designated for it, like in a dining room on dining table or mark a place for dining- like near kitchen (in Indian setup).
    • Avoid eating on bed, tv room, over sofa.
    • Don’t open potato chips packet over sofa/bed
    • Avoid food wastage going in sink/basin/drain
    • Clean the dining table/ dining place immediately after eating with detergent/disinfectant.
    • Try to eradicate cockroach from your house by using appropriate insecticide.
    • They are night dwellers, visible mostly in night. So if they are not visible during day time, don’t be in false belief of being free of them. They hide in dark cramped places
    • Seal cracks in floors and ceilings
    • Store all food in sealed containers
    • Don’t store waste in home

    Moulds:

    • Use 5% ammonia solution or vinegar (शिरका) to remove mould from bathroom, near चापाकल, and other places. You can use food grade vinegar to clean and remove the fungus from inside of चापाकल
    • Repair any water seepage in your home.
    • There shouldn’t be any पपड़ी/ broken area of paint, plaster, सीलन.
    • Moulds/fungus grow in humid air rapidly, use dehumidifier or AC or natural ways to reduce humidity like allowing sun light and cross ventilation of air.
    • Rapair indoor water leakage immediately if any.

    Pets:

    • Avoid the animal you are allergic to but don’t have to hate them! You can sill have other pets.
    • Find another home for your pet or keep them outdoor.
    • Vacuum carpets, mattresses and upholstery on daily basis
    • Use HEPA air purifier/filter to trap animal danders
    • Wash your hands after playing with pets, take a bath.
    • Change your cloth before going to work/school if you had contact with any animal known to cause allergy, it will also protect your work colleagues.

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  • Allergen: Chenopodium album

    Allergen: Chenopodium album

    Chenopodium album commonly known as बथुआ (हिंदी), chandanbethu (Bengali), chakavata (Marathi), badane bettaave (Kannada), vastuccira (Malayalam), cakkaavarttikkirai (Tamil), chakravarthi koora (Telugu) is a moderate allergen, an upright weed (30-80 cm long) very common in temperate regions, how’s almos everywhere in nitrogen rich soil, especially on wasteland. It is also gown as vegetable crop.

    Chenopodium album pollinates between August to December and October to January. It’s pollens measure about 14-50 micron in diameter. Patients with its allergy will get affected in these months.

    • It belongs to
    • Family: Amaranthaceae
    • Subfamily: Chenopodiaceae
    • Genus: Chenopodium
    • Species: Chenopodium album
    • Common name: Lamb’s-quarters, Goosefoot

    The major allergens are Che a 1, Che a 2 & Che a 3.

    Symptoms: Patients allergic to pollens of Cenopodium album / Lamb’s quarter show symptoms of allergic rhinitis and asthma.

    It shows cross reactivity with Amaranthus, Artiplex, Birch, Timothy grass etc.

  • Allergen: Acarus siro

    Acarus siro also known as Flour mite, Grain mite, Cereal mite or Forage mite belongs to

    • Phyllum: Arthropoda
    • Subphyllum: Chelicerata
    • Class: Arachinada
    • Sub class: Acari
    • Order: Sarcoptiformes
    • Superfamily: Acaroidea
    • Family: Acaridae
    • Genus: Acarus
    • Species: siro

    It is one of the many but important agricultural pest & environmental allergen earlier known as Tyroglyphus farinae.

    This pearly white pest with 8 pinkish or yellowish legs measures about 0.5 mm in length.

    A.siro is a perennial allergen with peak between May and August in some states.

    Aca s 13 is the important allergenic protein the other being Aca s 2.

    A.siro shows limited cross reactivity with Dermatophagoides species, but more with another storage mite Tyrophagus putrescentiae.

    Symptoms: storage mites can cause symptoms of allergic rhinitis and asthma usually in agricultural workers, farmers, millers, bakers etc.

    Oral mite syndrome occurs in atopic individuals shortly after eating foods made with mite contaminated wheat flour. Rarely it cause anaphylaxis resulting in death.

    Storage mite

  • Cat allergy

    • Cats- Felis domesticus or बिल्ली (Hindi) belongs to
    • Class: Mammalia
    • Order: Carnivora
    • Family: Felidae
    • Genus: Felis
    • Species: domesticus
    • Common name: Domestic cat

    Sensitization to cat allergens in India ranges between 2-19% in our different parts.

    Cat allergens are present in it’s dander, saliva and urine. These allergens get attached to different particles present in our surroundings and become airborne on little disturbances. Those attached to smaller particles of size <5micron remain airborne for long periods. Cat allergens can be found in places where cats have never been kept! They can be present in your blankets, furniture or clothes.

    The most important cat allergen is Fel d 1 (95%) which can cross react with allergens from other big cat species. The other cat allergens are: Fel d2 (albumin), Fel d3 (lipocalin), Fel d5w, Fel d7 (Von Ebner gland protein) and Fel d8.

    Few cat allergy patients show symptoms on exposure of dogs & horses allergens due to cross reactivity of albumin and lipocalins allergens.

    Symptoms: rhino conjunctivitis, asthma, atopic dermatitis (Fel d2).

    Pork-cat syndrome: is a condition where patients present with food related or idiopathic urticarial or anaphylactic symptoms after consumption of pork (or in lesser cases beef) but found sensitized to cat allergens after investigations.

    Cat

  • Wheat allergy

    Wheat also known as Gehun (Hindi), Gom (Bengali), Gahu (Marathi), Godhi (Kannada), Gothmbu (Malyalam), Godumai (Tamil), Godhumalu (Telugu) is an annual grass belonging to:

    • Family: Poaceae
    • Sub-family: Pooideae
    • Genus: Triticum
    • Species: Triticum sativum
    • Alternative name: Triticum aestivum
    • Common name: Wheat.

    Wheat is a mild allergen with flowering in high summer.

    Allergens: 1.3-beta-glucanase allergen is the major allergen. Wheat also contains the Group 1 to 5 allergens (Tri a 1 to Tri a 5), group 13 (Tri a 13) and profilin present in grass pollen of the Pooideae sub-family.

    Cross-reactivity: cross reactivity has been found to be present in the Pooideae sun family including the grass pollen (Poa pratensis, Phelum pratense, Lolium perenne) and the cereal pollen (Wheat, Barley, Rye).

    Symptoms: Wheat can cause 3 different diseases- pollen allergy, food allergy and Baker’s asthma.

    Baker’s asthma is an occupational allergy in which sensitisation occurs via inhalation of cereal flours.

    Cereal pollen allergy has a low prevalence, but may be important in sensitized individuals with occupational exposure to cereal pollen.

    Wheat

  • Egg allergy

    Egg also known as Anda (Hindi), Endu (Gujrati), Muttai (Tamil), Mutta (Malyalam), Gruddu (Telugu) is one of the most important allergens in childhood feeding but it’s allergy changes the quality of life.

    Egg allergy affects about 0.05% of our population.

    • Egg allergy is mainly caused by 4 allergens of the many proteins present in egg white.
    • 1. Ovomucoid (Gal d 1): is the most allergenic and dominant allergen found in hen’s egg white and reacts from both raw and cooked egg.
    • 2. Ovalbumin (Gal d 2): is the most abundant (58%) protein in the egg white and is 2nd most common allergen causing egg allergy. Patients allergic to Gal d 2 are able to tolerate cooked egg as this protein is heat labile.
    • 3. Ovotransferrin (Gal d 3): are heat resistant.
    • 4. Lysozyme (Gal d 4): are less allergenic.
    • In egg yolk, alpha-livetin (chicken serum albumin, Gal d 5) is the major allergen, also responsible for bird-egg syndrome. Yolk glycoprotein 42 is the another important allergen present in egg yolk.

    Cross reactivity: have been reported between hen’s egg and other bird eggs (turkey, duck, goose, seagull and quail). Few egg allergy patients also cross react with chicken meat due to chicken serum albumin.

    Symptoms: egg allergy is the 2nd most common food allergy (1st is cow’s milk allergy) and it is the most common allergy in children with atopic dermatitis. Egg allergy is mostly seen in childhood rarely in adults. Children often tend to outgrow their condition in adulthood.

    Egg allergy causes conditions such as itching, atopic dermatitis, rhinitis, conjunctivitis, bronchial asthma, angio-oedema, laryngeal oedema, urticaria, allergic eosininophilic gastroenteritis and anaphylaxis.

    Bird-egg syndrome is an IgE-mediated hypersensitivity disorder wherein a human develops an allergy to egg yolk, specifically to serum albumin, following sensitisation to inhalant avian antigens derived from sources such as bird’s blood serum, feathers, droppings and dander.

    It has been found that eggs heated in the presence of another substance such as wheat have lesser IgE reactivity as compared to eggs heated alone.

    Egg- important allergen in childhood

  • Milk allergy

    Milk known as Doodh (Hindi), Halu (Kannada), Pal (Tamil/Malyaalam), Pala (Telugu) causes allergies in about 0.05% of our population.

    Cow’s milk contains around 30-35 grams of proteins/litre of about 25 different varieties. Any of these proteins may act as an allergen. These proteins are broadly divided into caseins (80%) and serum (whey) proteins (20%).

    • The major allergenic milk proteins are:
    • Caseins (Bos d 8, which is a combination of Bos d 9 to Bos d 12)
    • Beta-lactoglobulin (Bos d 5) and
    • Alpha-lactalbumin (Bos d 4)
    • The other characterised allergenic milk proteins are:
    • Caseins: alpha s1 (Bos d 9), alpha s2 (Bos d 10), beta (Bos d 11), kappa (Bos d 12)
    • Whey: bovine serum albumin (Bos d 6), immunoglobulins (Bos d 7), lactoferrin.

    Cross reactivity: Cow’s milk allergens cross reactivity with milk of other mammals such as goats, sheep and buffalo. Milk from non/bovid mammals (mare,donkey,camel) shows better tolerance in some patients. Bovine serum albumin (Bos d 6) may cross react with raw beef, but is lost on cooking being heat sensitive.

    CMPA (Cow’s Milk Protein Allergy) are amongst the most common food allergies in all age groups. The prevalence of CMPA (estimated) in the first year of life is 1.6-3%, and decreases to less than 1% in children aged 6 years or older. Majority of the CMPA patients outgrow their condition. Children who out grow of their CMPA become tolerant to milk in baked form before fresh milk products as baking reduces protein allergenicity.

    Allergy to milk may manifest as an IgE mediated, non-IgE mediated or mixed manifestations. Typical IgE-associated symptoms appear immediately or within 1-2 hours after milk ingestion and affect the skin, the respiratory system, the GI tract and/or appear as systemic anaphylactic reactions in severe cases. Milk is the third most common food after peanuts and tree nuts that causes anaphylactic reactions, accounting to 10-19% of all food-induced anaphylactic cases.

    In non-IgE mediated disease the clinical symptoms affect mainly the gastrointestinal system including enterocolitis, proctitis, proctocolitis, enteropathy, irritable bowel syndrome, eosinophilic esophagitis and constipation. Respiratory symptoms and atopic dermatitis may also be seen (less commonly) in this presentation. The clinical manifestations of mixed manifestations may appear as atopic dermatitis and eosinophilic gastroenteropathies (esophagitis and gastroenteritis).

    Child having rashes over face with milk bottle visible in background
    Hair loss in milk allergic kid (same boy)
    Child has outgrown his CMPA with disappearance of rashes and no more hair loss

  • Allergen: Aspergillus fumigatus

    Aspergillus fumigatus is a fungus found in soil survives on organic debris and plays an essential role in recycling environmental carbon and nitrogen. They belong to

    • Kingdom: Fungi
    • Phylum: Ascomycota
    • Class: Eurotiomycetes
    • Order: Eurotiales
    • Family: Trichocomaceae
    • Genus: Aspergillus
    • Species: fumigatus

    A. fumigatus is characterised by green echinulate conidia, 2.5 to 3 micron in diameter, produced in chains basipetally from greenish phialides. It sporulates abundantly, with every conidial head

    Aspergillus fumigatus

    producing thousands of conidia (asexual spores) which are air-borne.

    Once the spores are in the air, their small size makes them buoyant, tending to keep them airborne both indoors and outdoors. Furthermore, their small diameter (2-3 micron) makes it possible for them to reach the lung alveoli.

    Outdoor habitat: soil, decaying plant materials, trees, compost, wood chips, hay and crops and stored grains.

    Indoor habitat: on dampened building materials (plasterboard, wood, chipboard, ceiling tiles, cardboard and insulation material), on indoor organic substrates such as house dust and other cellulose containing materials, in humidifier, air-conditioning systems and air ducts and filters, as well as on household articles made of linen, leather and paper.

    They are perennial in nature present pan over india with peak in summer and rains.

    Out of about 23 allergenic proteins derived from A. fumigatus Asp f 1, f 2, f 3, f 4, and f 6 are clinically significant.

    They have been shown to cross react with A. flavus, A. versicolor, A. niger and also with other fungal genera like P. notatum, Cladosporum herbarum, Alternaria alternata, Penicillium citrinum, Sacchromyces cerevisiae, Fusarium solani and Candida albicans.

    Over 80% of Aspergillus-related conditions, such as extrinsic allergic alveolitis, asthma, allergic sinusitis, chronic eosinophilic pneumonia, hypersensitivity pneumonitis, severe asthma with fungal sensitization (SAFS), and Allergic BronchoPulmonary Aspergillosis (ABPA) are caused by A. fumigatus.

  • Allergen: Dermatophagoides farinae

    • Dust mites are the most common allergens all over world. Let’s learn some basics about them! They belong to:
    • Phyllum: Arthropoda
    • Subphyllum: Chelcerata
    • Class: Arachinada
    • Order: Acari
    • Superfamily: Analgoidea
    • Family: Pyroglyphidae
    • Subfamily: Dermatophagoidinae
    • Genus: Dermatophagoides
    • Species: farinae

    Commonly known as ‘house dust mite’ or simply ‘dust mite‘

    Adult dust mites are barely seen to the naked eye but easily visible under low power microscope and have a size of about 0.2 to 0.4mm

    They thrive best at 75% to 80% relative humidity and 25*C to 30*C.

    Lifespan: 4-6 weeks

    50-80 eggs in lifetime

    Dust mites produce about 20 fecal pellets/day, varying in size from 20-40 micron and contain digestive enzyme derived allergens. These fecal pellets easily become airborne by little disturbances like making a bed, walking on a carpet, or moving on a pillow and take 20-30 minutes to settle down.

    Dust mites are light sensitive and photophobic, live deep within soft substrates, such as pillows, mattresses, and carpets, where moisture is retained and humidity fluctuations are minimal.

    HDM are the most common indoor allergens globally.

    D.farinae is a perennial allergen with seasonal variations. Their concentration increased in warm & humid climate.

    There are estimated about 30 allergens proteins of which Der f 1 and Der f 2 are most important. Der f 1 originates from the intestinal tract of the mite while Der f 2 is more abundant in the mite body. Both together are responsible for about 80-90% of D.f sensitised individuals.

    There is very less cross reactivity with storage mites. Der f 20 protein shows cross reactivity with shrimp, cockroach and other HDMs.

    HDM are considered as causative allergens for development of allergic rhinitis, asthma and eczematous lesions.

    House dust mite

  • ABPA

    ABPA, i.e. Allergic Broncho Pulmonary Aspergillosis is a frequently missed and under diagnosed cause of shortness of breath.

    It usually mimics asthma , but is a separate entity. It occurs due to hypersensitivity reactions in lungs to Aspergillus fungus allergen.

    Diagnosis:

    1. Either Skin prick test to Aspergillus positive, or Specific IgE against Aspergillus fumigatus more than 0.35 IU

    2. Total IgE more than 1000.

    Types:

    Depending on how much lung has been damaged

    1. ABPA-S: no damage to lung parenchyma

    2. ABPA-CB: Bronchiectasis present

    3. ABPA-CB-ORF: apart from Bronchiectasis Other Radiological Features present in chest HRCT

    Treatment:

    Mainly Oral steroids apart from supportive therapy for concomitant diseases and regular monitoring

    Allergen avoidance

    Chest physiotherapy

    Breathing exercises

    LTOT where needed

    Immunisation

    Patient education on side effects of oral steroids, teaching how to identify early signs, prophylactic measures.

    Clue:

    Severe asthma not getting controlled on high dose ICS-LABA.