A bit of bad news if you live in Tempe, Arizona, particularly if you live in or near Warner Ranch,  and are allergic to Ash pollen.

Arizona Ash is a medium to large deciduous tree, growing to 30-50 ft and found natively in Arizona around the Mogollon Rim at an elevation of 2000-6000 ft.  In contrast to the more common varieties of desert trees, such as Mesquite and Palo Verde, that to some look more like large bushes trimmed to look like a tree, the Arizona Ash provokes memories of the kind of stately shade trees found in the Midwest or Northeast, where many migrants to Arizona grew up.

I have heard that homeowners originally buying into the equestrian homesites in Warner Ranch (between Elliot and Ray Road and east of Ahwatukee) in the 80s were strongly encouraged, if not required, to plant an Arizona Ash tree.  The result is an area filled with mature Ash Trees.  The Ash trees began to pollenate around the first of February, a bit early this year, likely because of the warm, sunny weather. When the wind blows there will beenough Ash pollen in the air to affect the surrounding areas of Tempe, Chandler, and Ahwatukee for several weeks to come.

Cough is one of the most common symptoms prompting patients to see a doctor in the United States with an estimated 30 million trips to the doctor for this problem each year. More than 40% of the patients seen in our allergy and pulmonary practice between November and February complain of cough.

Cough is classified as acute, sub acute or chronic depending on how long the symptom has been present.   Acute cough lasts for less than three weeks and is most commonly the result of an acute respiratory tract infection. Other more serious causes of acute cough include pneumonia and in our clinic in Arizona, coccidiomycosis infection or valley fever.

A cough associated with typical cold symptoms may be called bronchitis, particularly when symptoms last for more than a week. Acute bronchitis is most often caused by a viral infection although other respiratory infections besides viruses, including Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Bordetella pertussis may be involved.  Although most viral infections cause symptoms lasting less than 2-3 weeks, some patients with viral or other upper respiratory tract infections will continue to cough for more than eight weeks after the acute infection.  This persistent cough may be the result of a type of airway injury.  Although the source of the infection is gone, the injury remains and takes time to heal.

Another important cause of acute cough in children in adults is pertussis (whooping cough).  Pertussis is a very contagious disease caused by the bacteria Bordetella pertussis. Before the advent of vaccinations in the 1940s, pertussis was a major cause of severe illness and death among infants and children.  Although cases of pertussis decreased by more than 99% after the introduction of pertussis vaccine, it remains a cause for concern, in part because of the incomplete protection provided by the vaccine and the increasing numbers of children that are never vaccinated.  In fact, pertussis is the only vaccine-preventable disease that is associated with increasing deaths in the United States.  In 2010, more than nine thousand cases of whooping cough were reported in California. At least ten infants died from the infection prompting the health authorities to declare a pertusis epidemic.

Pertusis infection usually begins with symptoms similar to the common cold although after several weeks, frequent and often violent coughing begins. The illness is most severe in infants and young children, particularly in those that have not been immunized. In adults, the only symptoms may be a persistent cough.

In a recent study published in The Journal of Allergy and Clinical Immunology (JACI), the risk of adults and children with asthma developing whooping cough was 1.7 times higher than those without asthma, suggesting that asthma significantly increased risk for whooping cough.

A cough lasting more than 4-6 weeks without a clear history of acute respiratory infection is considered chronic and is most likely the result of one of three conditions: asthma, rhinitis/sinusitis and gastroesophageal reflux disease.

Asthma and rhinitis/sinusitis are frequently the result of allergies and so a history of allergies or a positive allergy evaluation strengthens the likelihood that one of these conditions is behind the cough.

Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux disease (LPR) are conditions associated with the leakage of stomach contents into the esophagus.  In GERD, stomach acid refluxes into the lower esophagus causing irritation and damage.  Exposed nerves in the esophagus can cause cough as well as pain (heartburn).  In LPR, stomach contents may reach to the top of the esophagus causing direct irritation of the throat and possible sinuses.  The throat and upper airway are lined with cells that produce mucous as well as cells that have hair-like projections or cilia that sweeps the mucous to the back of the throat where it is swallowed.  Acid and protein-destroying enzymes in the refluxed stomach contents inflame and  damage the hair cells, hindering the ability to clear mucous.  The result is pooling of mucous in the back of the throat and recurrent cough to clear it.  It is estimated that 50% of patients with LPR have no other symptom of their condition other than cough and is therefore frequently missed.   GERD and LPR should be suspected if an evaluation for allergies, asthma, and sinus disease is negative and the cough fails to respond to conventional treatment.

When talking with a patient in our allergy clinic, so often the response to my question,  “Are there any pets in the home”, is “yes, a dog, but it is a hypoallergenic dog”.   I also hear, “My breed of dog does not have fur, it has hair”.  The idea being that, since people are allergic to dog “fur”, having a dog with hair rather than fur avoids the potential problem of dog allergy.

So is there such a thing as a hypoallergenic dog?  Are Poodles and Terriers really less allergenic than Golden Retrievers and Springer Spaniels?   A recent study published in the American Journal of Rhinology & Allergy was conducted to answer this question.

In this study, an Internet search was conducted to identify breeds frequently cited as being hypoallergenic. Dust samples were then collected from homes with a variety of both pure bred and mixed breed dogs.  Researchers have identified Canis familiaris 1 as the allergenic protein (allergen) responsible for dog allergy and the amount of this protein in the dust samples collected from the homes was compared between breeds believed to be hypoallergenic versus the non-hypoallergenic breeds.

Their results?  There was no difference in the amount of allergen shedding by dogs classified as hypoallergenic. The researches concluded that clinicians should advise patients that they cannot rely on breeds deemed to be “hypoallergenic” to in fact deposit less allergenic material throughout the home.

So like the unicorn, the hypoallergenic dog with hair rather than fur is likely a mythological creature, frequently found in word-of-mouth fairy tales and Internet sites, but yet to be found in pet stores.

I have been seeing a number of articles in the news recently reporting a theory that acetaminophen (Tylenol) use in children is linked to the development of asthma.  Proponents of the theory site several lines of evidence.  One is the observation that about 30 years ago parents began to give children with fever acetaminophen in place of Aspirin because of a link between Reye’s syndrome and Aspirin.  This occurred about the same time  that researches began to document a significant increase in asthma cases.  Also, studies have shown that parents of children with a diagnosis of asthma report given their children acetaminophen more frequently.

There are problems with using these observations to conclude that acetaminophen use causes asthma.  Most importantly is the fact that viral respiratory infections, like the rhinovirus that causes the common cold,  are by far the most important triggers of wheezing episodes in children. Many children with wheezing episodes associated with colds go on to develop true asthma but many do not.  In addition, researchers have suggested that certain viral respiratory infections such as the respiratory syncytial virus (RSV) may produce a type of airway injury that leads to the development of asthma.   Since children that have more frequent colds and associated conditions such as ear and sinus infections would be given acetaminophen more often for pain and fever, it is difficult to determine the true link.  In other words, is the observed increase in asthma the result of acetaminophen use or a change in the frequency and types of infections (as well as, perhaps, expectations of parents) that the acetaminophen is used to treat?   Other considerations include the use of antibiotics and vaccinations, declining family size, urbanisation, and pasteurization: all dramatically changed in the past thirty years.

One point is clear however: Reporting a link between Tylenol use and asthma will attract more readers than noting that sick children are more likely to have symptoms.

Alligator Juniper Payson, Arizona

Juniper is an evergreen coniferous shrub or small tree found at higher elevations throughout Arizona.  Most common are the  Aligator Juniper (named because of it’s distinctive rough bark) and Oneseed Juniper.  Both produce allergenic pollen during winter through early spring, and although these trees are not common in the desert regions, the pollen finds it’s way into the valley  in sufficient quantity to cause significant symptoms in sensitive individuals.  Several ornamental varieties of Juniper and Cedar are used in landscapes in the valley.   Because the pollen of most varieties of Juniper and Cedar are closely related, if you are allergic to one, you will have problems with all.

A study reported in an upcoming issue of The Journal of Allergy and Clinical Immunology (JACI), evaluated  the level of allergic antibodies  from birth to 2 years of age in children born into households that kept a pet cat or dog.

Using the population-based Wayne County Health, Environment Allergy and Asthma Longitudinal Study (WHEALS) birth cohort from southeastern Michigan, they analyzed one to four measurements of total IgE in  1,187 infants collected from birth to 2 years of age. Effects of prenatal dog and cat exposure on the shape and pattern of IgE throughout early life were then assessed.

Overall, children from homes with pets had a total IgE  that was an estimated 28% lower then children from  homes without pets. This protective effect of pet exposure was stronger within children born by caesarean section. It is hoped that future studies to  understand the potentially protective effect of prenatal pet exposure will lead to new treatments.

Parents should be aware that other studies have shown that, once a child has become sensitized (“allergic”) to cat or dog  dander, further exposure to a pet can lead to  more severe allergy and asthma symptoms.

Although food and diet fads come and go, there is general agreement that we should eat more raw fruits and vegetables.  Uncooked fruits and vegetables are the richest source of vitamins, minerals and antioxidants- nutrients often lacking in our over-processed, carbohydrate and fat-loaded, American diets.

For many people with pollen allergy, however, eating fruits and uncooked vegetables is not an option.  When they do, the result is often intolerable itching and irritation of the mouth, palate, and throat, and If they eat too much or too fast, they can develop abdominal pain and symptoms of a full blown allergic reaction.

This condition is called the oral allergy syndrome or pollen-food allergy syndrome and occurs when the antibodies that cause seasonal allergy symptoms, usually directed at grass, tree, or weed pollen, react with similar proteins found in food.   For example, patients with ragweed allergy may have problems with bananas, cucumber, and melons because these contain proteins that are similar to proteins found in ragweed pollen. When these anti-ragweed antibodies in the mouth and throat come into contact with the food, a mild allergic reaction occurs with itching and mild swelling. So eating a banana or piece of cantaloupe ends up making you feel like you just ate a bowl of fresh ragweed leaves.

In the same way, if you are allergic to birch tree pollen you may have problems eating a variety of fruits, vegetables, and nuts including apple, peach, apricot, cherry, plum, pear, almond, hazelnut, carrot, celery, parsley, caraway, fennel, coriander, aniseed, soybean and peanut.  Birch trees are common throughout the northern United States and Europe but are rare in Arizona.  However, allergy to Arizona Sycamore, a tree common to mountain and transition zones of Arizona, has been associated with reactions to apple, hazelnut, lettuce, corn, kiwi, peach, and peanuts, and green beans.  Sensitivity to Mugwort, an allergenic weed also prevalent in the Northern United States and Northern Europe, can cause reactions to carrot, celery, parsley, caraway, fennel, coriander, aniseed, bell pepper, black pepper, garlic, and onion as well as mustard, cauliflower, cabbage, and broccoli.

More important to the Southwest is sagebrush sensitivity, which is associated with reactions to carrot and celery.

An important distinction between the oral allergy syndrome and other types of food allergy is the rare occurrence of more serious allergic symptoms.  This is because the proteins in the fruits and vegetables that cause the oral allergy syndrome are very fragile and easily destroyed by digestive enzymes in the mouth and stomach.   So by the time the food leaves the mouth or stomach, the body no longer recognizes it as an allergen.  Cooking also denatures or destroys the allergenic proteins so that foods that cannot be tolerated when raw can be eaten after cooking.  This works out for banana bread and apple pie but cooked watermelon is just not the same.

In Arizona, one of the challenges patients and physicians face during February and March is determining if that runny nose, scratchy throat, and sinus pain is the beginning of the spring allergy season, a late winter cold, or worse.  Here are a few clues to help sort it out.

1. Allergy itches.  Most seasonal allergy attacks involve itching, either of the eyes, the nose, the throat, or skin.  When an allergic reaction occurs, histamine is released into the tissues causing redness, swelling, and itching.  Histamine is also released during a viral cold (which is why antihistamines are frequently prescribed for a cold) but this is not the primary chemical mediator causing symptoms.  If there is no itching, it probable isn’t allergy.
2. Colds last about a week. Viral cold symptoms peak around day three, begin to level off by day five, and then begin to resolve.  You may not be well by the seventh day but you should be significantly better compared to how you felt on day three.  A sinus infection is usually a viral cold that becomes complicated by a bacterial infection.  It begins like a cold but rather than getting better by day seven, things are getting worse with increased discharge, pain, and possible fever.  You should see a doctor if cold symptoms persist or worsen beyond the seven day mark.  The allergy timeline is much less predictable with allergy symptoms coming and going throughout the season.
3. Everyone else is sick.  If everyone in your cubicle, classroom, or home has the same deep cough or sore throat, it is likely a cold.  During a rough allergy season, a lot of people may be sneezing at the same time, but those affected do not cluster in a family, school,  or work-place the way a communicable virus does.
4. Olive trees in winter.   If you know what you are allergic to (Olive trees, for example) and you know when they pollinate (Olive tree in April), it is unlikely that your February and early March symptoms are caused by allergies (if Olive is the only thing your allergic too).

Non-stop sneezing, horrible itchy eyes, wheezing and coughing,  all during the one time of year when allergies are supposed to be hibernating!  The bermuda grass is still dormant, the weeds are frozen from the recent frost, and the citrus and Olive trees will not start budding for several months.   What could possible be causing all this allergy misery in the middle of winter?

The answer is Juniper and Cedar pollen. Although a few ornamental varieties of these evergreen trees are found in yards around the valley, they are not as numerous as Mesquite, Palo Verde, Palm, or Acacia trees.   However,  at higher elevation, varieties of Juniper such as Oneseed Juniper (Juniperus monosperma) or  Alligator Juniper  (Juniperus deppeana) cover thousands of acres in every direction surrounding Phoenix.    When conditions are right, a cloud of Juniper pollen is carried by the winds down into valley where it becomes part of the brown haze hanging over the city.

So if you are sneezing and itching in January and February in Phoenix, and are wondering what’s going on, look to the hills.

Alligator Juniper Payson, Arizona

Sulfites are a group of similar chemicals that are commonly used as a food enhancer and preservative to maintain food color and prolong shelf-life, prevent the growth of micro-organisms, and to maintain the potency of certain medications. They may come in various forms, such as:

• Sulfur dioxide
• Potassium bisulfite or potassium metabisulfite
• Sodium bisulfite, sodium metabisulfite or sodium sulfite

The use of sulfites as preservatives in foods and beverages increased dramatically in the 1970′s and 1980’s. After several cases of severe reactions to sulfites were reports, a ban by the FDA went into effect in August, 1986. This ban prohibited use of sulfites in fresh fruits and vegetables. Although reactions to sulfites were recognized initially with salad bars in restaurants, this is no longer a common source for sulfite exposure. Sulfites continue to be used in potatoes, shrimp, and beer/wine, and are also used in the pharmaceutical industry. Although shrimp are sometimes treated with sulfites on fishing vessels, the chemical may not appear on the label. A list of foods associated with sulfites can be found below.

Sulfites occur naturally in all wines to some extent and are commonly introduced to arrest fermentation at a desired time, and may also be added to wine as preservatives to prevent spoilage and oxidation at several stages of the winemaking.  In general, sweet (dessert) wines contain more sulfites than dry wines, and white wines contain more sulfites than red wines.  In the United States, wines bottled after mid-1987 must have a label stating that they contain sulfites if they contain more than 10 parts per million.

Labeling regulations don’t require that products indicate the presence of sulfites in foods other than wine; however, many companies voluntarily label sulfite-containing foods. Regulations do exist that require that ingredients lists show sulfites if they were added to a product, but this requirement applies only if they were intentionally added in formulation and not if they are contained in an ingredient. If a product includes an ingredient that contains sulfites, such as dried fruit, then the ingredients label will list only “dried fruit” and is not required to indicate whether the dried fruit itself contains sulfites. Furthermore, the products most likely to contain less than 10 ppm (fruits and alcoholic beverages) do not require ingredients labels, so the presence of sulfites is usually undisclosed.

Most beers no longer contain sulfites. Sulfites are added to many medications, including some of the medications given to treat asthma and allergic reactions.

Although a reaction to sulfite is not a true allergy, individuals who are sensitive to it may experience a variety of symptoms including asthma, diarrhea, abdominal pain and cramping, nausea and vomiting, hives, itching, localized swelling, difficulty in swallowing, faintness, headache, chest pain, loss of consciousness, “change in body temperature,” “change in heart rate,” and non-specific rashes.  For normal individuals, exposure to sulfite appears to pose little risk. Sulfite-sensitive asthmatics, however, are at risk of having  a severe asthma attack when exposed to sulfites.

To date there is no specific diagnostic test, other than a food challenge, available to determine if someone has a true sulfite sensitivity.   A double-blinded, placebo-controlled, food challenge in which neither the doctor of the patient knows knows whether a food containing sulfites or a placebo is given while symptoms are monitored is required to confirm a case of suspected sulfite sensitivity.

Foods Frequently Containing Sulfites

1. Alcoholic/non-alcoholic beer, cider, wine
2. Baked goods, e.g., breads, cookies, pastries, waffles
3. Bottled lemon and lime juice/concentrate
4. Canned/frozen fruits and vegetables, e.g., mushrooms, sliced apples, olives, peas, peppers, pickles, pickled onions, tomatoes
5. Cereal, cornmeal, cornstarch, crackers, muesli
6. Condiments, e.g., coleslaw, horseradish, ketchup, mustard, pickles, relish, sauerkraut
7. Deli meat, hot dogs, sausages
8. Dressings, gravies, guacamole, sauces, soups, soup mixes
9. Dried fruits/vegetables, e.g., apples, apricots, coconut, mincemeat, papaya, peaches, pears, pineapple, raisins, sun dried tomatoes
10. Dried herbs, spices, tea
11. Fish, including crustaceans and shellfish, e.g., shrimp (fresh/frozen)
12. Fresh grapes, lettuce
13. Fruit filling, fruit syrup, gelatin, jams, jellies, marmalade, molasses, pectin
14. Fruit/vegetable juices, e.g., coconut, grape, sparkling grape, white grape
15. Glazed/glacéed fruits, e.g., apples, grapes, maraschino cherries
16. Potatoes, e.g., frozen french fries, dehydrated, mashed, peeled, pre-cut
17. Snack foods, e.g., candy, chocolate/fruit bars, tortilla/potato chips, soft drinks, trail mix
18. Soy products
19. Starches, e.g., corn, potato, sugar beet; noodles, rice mixes
20. Sugar syrups, e.g., glucose, glucose solids, syrup dextrose
21. Tomato paste/pulp/puree
22. Vinegar, wine vinegar