Manual of Pediatric Allergy Major K Nagaraju
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Approach to Allergic Patient1

Major K Nagaraju
 
INTRODUCTION
Allergic disease is one of the three most common reasons why patients attend their family physician. Respiratory diseases represent about 25 percent of all visits to general practitioners and about 80 percent of patients with recurrent presentations are found to be allergic.
Allergy can affect virtually any organ system. Common types of presentation include conjunctivitis (eyes), rhinitis (nose), urticaria and angioedema or atopic (allergic) dermatitis (skin), asthma (lungs) and anaphylaxis (multiorgan). Evaluation of suspected allergy must include a detailed medical history, comprehensive physical examination and appropriate diagnostic tests. Diagnostic tests are detailed in the next chapter.
 
HISTORY
The most important component of the evaluation of a possible allergic problem is the patient's history. A careful history is the basis for the diagnosis and management of allergic diseases. The principle of history taking is the same for any medical problem (When, Where and what). Every Allergy clinic must have a questionnaire to be filled up by the patient and the physician. In no other medical disease is the history more important. Without a thorough history, one cannot investigate the patient appropriately. A check form for history taking is given in Appendix 1(A) page 6.
 
CHIEF COMPLAINTS
Patient must be given ample time to explain the symptoms. Many state that they have “sinus” or “permanent cold”. They describe a wide array of symptoms ranging from itchy nose, eyes, or palate to runny nose or postnasal drainage to nasal congestion.
Table 1   Key features of the history
• Worsening of symptoms on exposure to aeroallergens
• Are symptoms better away from home?
• Seasonal variation (Pollen)
• Year round (HDM)
• A family history of atopy
• Repeatability
• The presence of associated allergic condition
• Dietary factors, e.g. hives within 1 hour of eating
• Timing of symptoms, e.g. day, night, seasonal, at school, at home
Table 2   Ages at which certain Allergic disorders are most likely to first occur
Infancy
Atopic dermatitis, food allergies
Childhood
Asthma, Perennial Allergic Rhinitis
Adolescent
Seasonal Allergic Rhinitis
Early adulthood
Urticaria
Adult
Urticaria, Venom allergy
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Sinus pressure and headaches are frequently cited as symptoms. “Popping or fullness of the ears”, implying Eustachian tube dysfunction, is an often heard complaint. Asthma symptoms may be overt and present as wheezing, but descriptions may be more subtle, such as cough, tightness in the chest, or inability to get a good breath or let all the air out of the lungs.
 
TRIGGERS
What seems to trigger symptoms? Enquire about cross-reaction with food substances. Ex: Latex cross-reacts with Banana and Tree Pollen with fruits. Food allergies are unusual if non- atopic. Patients often blame chronic urticaria on food.
History should help delineate the asthma as mild, moderate or severe. Questions to determine the extent of asthma control include type and amount of inflammatory medication used (type of delivery system and quality of inhaler technique), frequency of respiratory symptoms and need for β-agonists, interference with daily activities or sleep and diurnal peak flow variability if known. Degree of severity will ultimately dictate choice and intensity of treatment. History of recurrent use of antibiotics, frequent colds or cough in a supine position may point to chronic sinusitis. Gastroesophageal reflux can present solely as cough and sometimes mimic or exacerbate asthma.
 
ENVIRONMENT
In most cases, the patient will stipulate if symptoms are worse inside the house or outdoors.
Indoor allergens are recognized as important triggers and sensitizers of the allergic patient.
Table 3   Anaphylaxis symptoms
• Erythema
• Pruritus
• Urticaria
• Angioedema–face, eyes, lips, tongue, throat
• Hypotension
• Collapse, LOC
• Vomiting, abdopain, diarrhea
• Rhinoconjunctivitis
Table 4   Skin symptoms
• Itch
• Erythema
• Macules/papules
• Wheals
• Excoriation
• Vesicles
• Distribution on palms/soles
Table 5   GI tract symptoms
• Oral itch/swelling (angioedema)
• Vomiting/diarrhea common in food allergy
• Intolerance symptoms notably bloating, diarrhea, constipation
Table 6   Nasal and eye symptoms
• Itch
• Sneeze
• Rhinorrhea
• Congestion
• Loss of smell
• Postnasal drip
• Sinus pain
• Headache
• Conjunctivitis – suggests atopy
• Tearing
Table 7   Chest symptoms
• Wheezing
• Chest tightness
• Breathlessness
• Cough
• Seasonal exacerbations
• Nocturnal symptoms
3
Is patient exposed to irritants? Ex: Agarbatti smoke, mosquito coil, strong odors, perfumes and cleaning solvents.
Outdoor allergens: Enquire about exposure to irritants ex: automobile pollution and allergens (Pollens). Trees, grasses and weeds can wreak havoc on an allergic sufferer. Likewise, different pollens may predominate in particular region.
Pet History: Particular attention should be given to any exposure to pets. Do the pets sleep in the bedroom or on the bed?
 
DRUG HISTORY
Patient is taking any antibiotics, NSAIDs, opiates or ACE inhibitors are to be enquired. What are the current medication patient is taking? Enquire about if patient has taken any over the counter medications or herbal/ complementary products. Has patient taken anesthetic medicines recently? What medications patient is taking for the allergic disease currently especially inhalation therapy for asthma or nasal allergy? Frequent use of decongestant nasal spray can lead to rebound nasal congestion, also called rhinitis medicamentosa.
 
Past Medical History
Past history of atopic symptoms and prior autoimmune disease esp. thyroid disorders and regular β blocker usage are to be enquired. Previous history of surgery is to be enquired for Latex allergy.
 
Family History
Family history of an allergic disease like asthma and food allergies should be sought. The genetics of allergy are not entirely understood, but a parent with atopy roughly doubles a patient's chance of being atopic. Risk of atopy is increased from 25 percent in the general population to about 75 percent when both parents are atopic. In one study, 90 percent of allergic asthmatic children had one or both parents who were atopic. Maternal asthma is a risk factor for the sibling.
 
Social history
 
Housing
Enquire about using carpets, staying in dusty environment and ventilation of the house. Type of home and the presence of a basement may be important. For example, a wet environment tends to produce growth of moulds and dust mites. House dust mite is likely the most common allergen in our society. Therefore, the kind of bedding and type of flooring may be relevant to understand in a given patient. Day-care facilities can be an insidious source of recurrent viral and bacterial exposure for children.
 
Smoking
Is patient exposed to passive smoking? What type of cooking fuel used in the house?
Occupation history is very important in older children and adolescents as child labor is common in our country.
The physical examination may be entirely normal at the time of examination, because allergy symptoms and signs are often evanescent. The examination should emphasize the organs involved with allergy symptoms.
 
Pitfalls in History
  1. Absence of known contact with pets does not exclude sensitization to animals or symptoms on exposure. Several recent studies show very high level of cat allergens in homes without cats, at 4school, in offices, cinemas and even doctor's office.
  2. Patients with perennial disease have most of their symptoms in the bedroom during the early morning although the causal agent is not necessarily in the bedroom.
  3. Patients who have strong aeroallergen sensitivity and chronic low dose exposure to the allergen, e.g., house dust mite or cat, will not notice immediate symptoms at home, but will notice symptoms from irritants (due to a nonspecific nasal hyperactivity) like smoke, cold air and perfumes. The patient will then assume these are the allergens, when they are merely secondary irritant triggers. Therefore the case history is rarely informative with regard to house dust mite allergy. A carefully taken history should be followed by an appropriate physical examination.
 
PHYSICAL EXAMINATION
An allergic patient's history may direct the clinician's examination to a particular area or organ system. Each patient should be approached in a systematic way. Often physical examination may be normal; lack of findings does not rule out allergy.
Vital signs are starting point in any examination. Pulse rate and pulses paradoxicus greater than 10 mm Hg are two of the most sensitive indicators of severe airway obstruction.
With the worldwide increase in use of inhaled corticosteroids for the treatment of allergic respiratory disease, growth in children has been more closely scrutinized. Height and weight should be measured in children on a periodic, at least annual basis.
Examination of the main target organs of allergic diseases like upper airways, ears, pharynx, nose, eyes, chest and skin should be done thoroughly.
 
Face
Clues to allergy are often seen in the patient's face. Discoloration of the infra-orbital skin or “allergic shiners” may imply nasal congestion and subsequent lymph stasis. Extension of the mid-face or adenoid facies in children with adenoid hypertrophy, an infra-orbital crease or Dennie's line and a transverse crease along the lower half of the nose are frequent but not absolute indicators of underlying allergy. Described in detail in chapter Clinical Features and Diagnosis of Allergic Rhinitis.
 
Eye
The eye examination is concerned principally with the state of the tarsal (lower lids) or palperbral (upper lids) and bulbar conjunctivae.
 
Ears
Tympanic membranes should be visualized. Tympanosclerosis implies previous recurrent otitis. If the light reflex is not well appreciated or history suggests Eustachian tube dysfunction, the tympanic membranes should be examined while the patient performs a Valsalva maneuver or with insufflators to judge the functional patency of the Eustachian tube.
 
Nose
The nose is best examined with torch. Look for deviated septum, hypertrophied inferior turbinates and any discharge.
 
Throat
The size and character of the tonsils should be noted. Finally, estimation of the depth and width of the oropharynx may lead to suspicion of obstructive sleep apnea. For those patients taking inhaled corticosteroids, thrush on the 5tongue and soft palate should be excluded at each visit.
 
Neck
The neck must be palpated to search for adenopathy. Accessory muscles, use of sterno-cleidomastoid muscles should not be missed because it is another sign of marked airway obstruction.
 
Respiratory System Examination
The lower respiratory system examination is particularly relevant in the asthmatic patients. Configuration of the chest wall should be noted; in particular, pectus excavatum, kyphosis, lordosis and scoliosis should be ruled out by inspection. Intercostal retractions may imply severe obstructive disease.
 
Skin
The skin is commonly affected by allergy, although skin findings are often falsely attributed to allergic disorders. Individuals with atopic dermatitis have dry skin. Look for lesions of urticaria, dermatographism. The lesions of angioedema are indurated and usually not as well demarcated as urticarial lesions.
 
POINTS TO REMEMBER
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Appendix 1A Model allergy case sheet in our center
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FURTHER READING
  1. “ABAI: American Board of Allergy and Immunology”. Archived from the original on 2010-11-16. Retrieved 2007-08-05.
  1. Bruce L Wolf. Approach to the Allergic Patient. In: Allergic diseases: Diagnosis and Treatment. Phil Lieberman and John A Anderson (eds). 3rd edition. Humana Press,  Totowa,  New Jersey, 2007;15-25.
  1. Buttram J, More D, Quinn J. Allergy and Immunology. The Complete History and Physical Exam Guide. 2003:53-69.
  1. Francis M Rackemann. History taking in allergic diseases. JAMA. 1936;106(12):976-9.
  1. Gell PGH, Coombs RRA. Clinical Aspects of Immunology. Blackwell.  London:  1963.
  1. Ishizaka K, Ishizaka T, Hornbrook MM. “Physico-chemical properties of human reaginic antibody. IV. Presence of a unique immunoglobulin as a carrier of reaginic activity”. J. Immunol. 1966;97(1):75-85. PMID 4162440.
  1. Johannes Ring. Clinical Manifestation and Classification of Allergic Diseases. 2005; In: Allergies in Practice. Springer  Germany, pp:1-7.
  1. Von Pirquet C. “Allergie”. Munch Med Wochenschr. 1906;53(5):1457. PMID 20273584.