Clinical Allergy: Diagnosis and Management

502 Pages·2009·3.26 MB·English

by  Gerald W. Volcheck (auth.)

Clinical Allergy
Current Clinical Practice
Neil S. Skolnik, SERIES EDITOR
For other titles published in this series, go to
www.springer.com
select the subdiscipline
search for your title
Gerald W. Volcheck
Clinical Allergy
Diagnosis and Management
Gerald W. Volcheck
Consultant, Division of Allergic Diseases, Mayo Clinic
Rochester, MN
Assistant Professor of Medicine, College of Medicine,
Mayo Clinic
Series Editor
Neil S. Skolnik
Abington Memorial Hospital
Abington, PA 19001
USA
ISBN 978-1-58829-616-0 e-ISBN 978-1-59745-315-8
DOI: 10.1007/978-1-59745-315-8
Library of Congress Control Number: 2008936256
© 2009 Mayo Foundation for Medical Education and Research. All rights reserved. This book is protected
by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form by
any means, electronic, mechanical, recording, or otherwise, without written permission from Mayo
Foundation, Section of Scientific Publications, Plummer-10, 200 First Street SW, Rochester, MN
55905.
Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions
or for any consequences from application of the information in this book and make no warranty, express
or implied, with respect to the contents of the publication.
The authors, editors, and publisher have exerted efforts to ensure that drug selection and dosage set forth
in this text are in accordance with current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of
information relating to drug therapy and drug reactions, the reader is urged to check the package insert
for each drug for any change in indications and dosage and for added warnings and precautions. This is
particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of health care providers to
ascertain the FDA status of each drug or device planned for use in their clinical practice.
Cover illustration: Figure 6, Chapter 2, “Environmental Allergens”
Printed on acid-free paper
9 8 7 6 5 4 3 2 1
springer.com
To my wife Mary Margaret and children
Joseph and Allison for their love,
encouragement, and support.
Series Editor’s Introduction
Diseases exacerbated by allergy, as well as primary allergic disorders, are among
the most common disorders seen by primary care physicians. Seldom does an office
session occur where there are not two or three patients with some manifestation of
allergic disease ranging from asthma, to allergic rhinitis, to urticaria. The science
of allergy and immunology has exploded over the last two decades, making it
important for physicians to have an effective reference to help update their knowl-
edge of the field. In a recent survey conducted by the Academy of Family
Physicians, 50–60% of family doctors responded that they had a moderate to high
need for further allergy education.1
Clinical Allergy: Diagnosis and Management by Dr. Volcheck is an excellent,
detailed overview of the field of allergy, with an eye toward relevance and the right
level of detail for busy primary care physicians. Dr. Volcheck presents the evidence
clearly and gives clear opinions and recommendations when the evidence still falls
short. Starting with an overview of the immune response, then discussing environ-
mental allergens, the book then addresses details of allergy testing and immuno-
therapy. This chapter is particularly well done and answers relevant, ongoing,
natural questions that come up in all primary care offices, which I have not seen
well answered in general articles on the topic.
Dr. Volcheck then discusses the specific allergic-influenced diseases including
allergic rhinitis, ophthalmic allergies, asthma, urticaria and angioedema, atopic
dermatitis, drug allergies, food allergies, anaphylaxis, and stinging insect allergies.
As I read through this book, I was amazed at how many topics were covered in
which I had clinical questions while seeing patients, and which the chapters of the
book readily answered.
In summary, Clinical Allergy: Diagnosis and Management by Dr. Volcheck from
Mayo Clinic is a valuable addition to the literature and is effective at answering the
many questions that come up in the day-to-day care of patients with allergic diseases.
It deserves a place on our shelves as a book of study, understanding, and reference.
Abington, Pennsylvania, USA Neil Skolnik
1 American Academy of Family Physicians, Continuing Medical Education Topics Surveys, April
2006, accessed at http://www.aafp.org/online/en/home/aboutus/specialty/facts/30.html, Feb 2008
vii
Preface
T he purpose of this book is to provide a practical clinical overview for the com-
mon disorders encountered in the specialty of allergy. Allergic diseases affect
nearly one-fourth of the population and cause or contribute to significant chronic
illness. Because allergic diseases are so common, they are seen by a wide variety
of health care providers. With this in mind, Clinical Allergy: Diagnosis and
Management has been designed to be easily readable and to provide clinically
applicable information for both the nonallergist and the allergist. The text is not
encyclopedic. Instead, the intent is to unravel the mystery of allergy and to provide
a logical framework for the evaluation and management of allergic disorders. The
introductory chapters focus on the human immune response, environmental allergens,
and the different types of allergy testing. The subsequent chapters focus on the
common allergic conditions seen in the office or clinic, including rhinitis and
rhinosinusitis, allergic eye disease, asthma, urticaria and angioedema, atopic and
contact dermatitis, drug allergy, food allergy, anaphylaxis, and stinging insect
allergy. “Cross-talk” between chapters helps show the interrelationships among the
various allergic disorders. The chapters begin with a review of pathophysiologic
mechanisms and then consider a clinically structured approach to diagnosis and
management of the disorders. In addition to pharmacologic treatment, the importance
of nonpharmacologic management and patient education is emphasized. The primary
clinical pearls of daily clinical management of the allergic patient are highlighted
by the clinical vignettes at the end of each chapter.
The book is designed for primary care providers, medical students, residents,
and junior allergy fellows. Senior allergy fellows and seasoned allergists will also
likely find practical, clinically useful information in this book.
I am indebted to Susan R. Miller, John P. Hedlund, Roberta Schwartz, and
Dr. O.E. Millhouse for their superb editorial assistance, to Drs. Mark D.P. Davis
and Keith H. Baratz for providing excellent photographs of allergic skin and eye
disorders, and to the medical students, residents, fellows, colleagues, and most
importantly the patients who bring these pages to life.
Rochester, Minnesota, USA Gerald W. Volcheck
ix
Contents
Series Editor’s Introduction .......................................................................... vii
Preface ............................................................................................................. ix
1 Overview of the Human Immune Response .......................................... 1
1.1 Introduction ..................................................................................... 1
1.2 Innate Immune System ................................................................... 2
1.3 Acquired Immune System .............................................................. 7
1.3.1 Immunogens and Allergens ................................................. 8
1.3.2 Antigen-Presenting Cells .................................................... 8
1.3.3 Major Histocompatibility Complex .................................... 9
1.4 T- and B-Cells in the Acquired Immune Response ........................ 11
1.4.1 T-Lymphocytes .................................................................... 11
1.4.2 B-Lymphocytes and Immunoglobulins ............................... 16
1.5 Lymphoid Tissues ........................................................................... 20
1.6 Tolerance: Distinguishing Self from Nonself ................................. 21
1.7 Cytokines ........................................................................................ 22
1.7.1 Cytokines Produced by Antigen-Presenting Cells .............. 22
1.7.2 Cytokines in the Humoral Immune Response ..................... 23
1.7.3 Cytokines in the Cellular and Cytotoxic
Immune Response ............................................................... 24
1.7.4 Cytokines in the Allergic Immune Response ...................... 24
1.7.5 Anti-Inflammatory Cytokines ............................................. 25
1.8 Chemokines ..................................................................................... 26
1.9 Complement .................................................................................... 28
1.10 Inflammatory Cells ......................................................................... 28
1.10.1 Eosinophils ........................................................................ 28
1.10.2 Mast Cells.......................................................................... 29
1.10.3 Basophils ........................................................................... 29
1.11 Primary Mediators of Inflammation ............................................... 30
1.11.1 Histamine .......................................................................... 30
1.11.2 Arachidonic Acid Metabolism .......................................... 31
1.11.3 Cyclooxygenase Products: Prostaglandins ........................ 32
xi
xii Contents
1.11.4 Lipooxygenase Products: Leukotrienes ............................ 33
1.12 Allergic Response to an Allergen: Summary ................................. 34
1.13 Immune-Modulating Medications in Allergic Disease .................. 34
1.13.1 CpG-DNA ......................................................................... 35
1.13.2 Omalizumab ...................................................................... 35
1.13.3 Anti-TNF ........................................................................... 35
1.13.4 Immunotherapy ................................................................. 36
1.13.5 Corticosteroids .................................................................. 36
1.13.6 Immunophilins .................................................................. 37
1.14 Summary ......................................................................................... 37
Suggested Reading ..................................................................................... 39
2 Environmental Allergens ......................................................................... 41
2.1 Overview of Allergens ...................................................................... 41
2.2 Pollens ............................................................................................... 42
2.2.1 Pollen Counts ........................................................................ 42
2.2.2 Tree Pollens ........................................................................... 46
2.2.3 Grass Pollens ......................................................................... 50
2.2.4 Weed Pollens ......................................................................... 54
2.2.5 Environmental Control: Outdoor Pollens ............................. 57
2.3 Fungal Allergens ............................................................................... 57
2.3.1 Classification ......................................................................... 58
2.3.2 Alternaria alternata .............................................................. 60
2.3.3 Aspergillus ............................................................................ 60
2.3.4 Cladosporium herbarum ....................................................... 61
2.3.5 Penicillium ............................................................................ 62
2.3.6 Basidiomycetes ..................................................................... 62
2.3.7 Other Fungi ........................................................................... 62
2.3.8 Avoidance of Fungal Allergens ............................................. 63
2.4 Indoor Allergens ............................................................................... 63
2.4.1 Mite Allergens....................................................................... 63
2.4.2 Mite Allergen Avoidance ...................................................... 65
2.5 Animal Allergens .............................................................................. 67
2.5.1 Cat Allergen .......................................................................... 68
2.5.2 Dog Allergen ......................................................................... 69
2.5.3 Horse Allergen ...................................................................... 69
2.5.4 Cow Allergen ........................................................................ 70
2.5.5 Mouse Allergen ..................................................................... 70
2.5.6 Rat Allergen .......................................................................... 70
2.5.7 Guinea Pig Allergen .............................................................. 70
2.5.8 Rabbit Allergen ..................................................................... 70
2.5.9 Animal Allergen Environmental Control .............................. 71
2.6 Cockroach Allergen .......................................................................... 72
2.6.1 Cockroach Environmental Control ....................................... 72
2.7 Clinical Vignettes .............................................................................. 74