Friday, January 5, 2018


She was only 12 yr old . went out for christmas break with family in a nearby resort
but had to be hospitalised due to severe abdominal pain.
Was kept on symptomatic treatment and was being investigated thoroughly as the pain was recurrent.
The only clue in investigations was significant  eosinophilia and  Ascites.
All the common causes of ascites were ruled out .
Ascitic fluid was tapped which revealed significant eosinophils in ascitic fluid.
Endoscopy was normal .
She was treated with steroids to which she responded.
Three months later she again developed pain abdomen with bleeding per rectum.
She was hospitalised as ultrasoung examination revealed ascites progressing rapidly.
Ascitic fluid was full of eosinophils,
Colonoscopy was done with biopsies at all levels.
Colon , cecum , ileum , rectum at various levels revealed significant eosinophilic infiltration
EOSINOPHILIC GASTROENTERITIS is a well known entity though is very rare.
She was investigated further for food allergy which revealed SIgE raised for Fish and ST also positive for fish.
History revealed that during both episodes she had consumed fish .
She was treated with steroids but was instructed to avoid all sea food strictly .
She is symptom free for past 7 months.
It does not mean that FISH or sea Foods are bad but it simply means that one mans food can be another ones poison . ROLE of FOOD ALLERGY testing in difficult situations is highlighted here.


Symptoms which begin as watery , itchy , blocked nose,  persist for days and keep recurring every now and then could be due to Allergic rhinitis.
People just manage this with home remedies or over the counter pills and carry on for years together.
This results into chronic sinusitis , Asthma , headaches spread of allergy to eyes resulting into red itchy eyes.
Allergy is like growing tree , if the roots are intact new branches are bound to come .
Allergic rhinitis may become quiet but can erupt as Urticaria , rashes , iching etc.
Migraine may also be due to allergy.
Abdominal symptoms can also be due to food allergy or even an accompniment of allergic rhinitis , asthma , skin allergy etc.
the severe manifestations can be recurrent  angioedema which can be life threatening.
I have seen patients with swelling of tongue so that it is difficult to fit tongue within the mouth
resulting into medical emergency.
Laryngeal edema causes choking and is always life threatening.
Therefore nasal allergy should not be neglected.
Treatment is succesful if scientific and persistent.

Sunday, April 10, 2016


 Allergy season has started , patients who suffer from seasonal allergies alone have started developing rhinitis and Asthma symptoms.
Even those who suffer from perennial allergy have started having aggravation in symptoms.
All this can be prevented if patients start  preventive treatment in preseason even when they are not suffering.
Its important to educate the patients to visit doctor surely in early March and August for preventive treatment.
Those who are already on treatment have to ensure that they are regular on their nasal spray and inhalers and follow up with doctors.
Nasobronchial seasonal allergy can best be tackled by scientific approach.

Thursday, November 26, 2015


Every time I see an Asthma  patient in emergency I realize that  its communication by us doctors
which was not effective otherwise nothing could land him in emergency.
He started feeling confident of his Asthma control that he stopped coming for follow up and stopped use of inhaler in Sept October on his own. Remained well for 4 days but landed in emergency on 5th day. He did not have any written protocol , he panicked and started with multiple puffs on Steroid inhale instead of the bronchodilator salbutamol.
This is one of the stories.
Its wrong to abruptly stop the inhaler in the aggravating season even if you feel well.
Inhalers could be changed stopped only  on advise of doctor. Even after stopping ,
one should make use of peak flow meter to judge that airways are not in spasm. If they are ,use brochodilator followed by steroid preventive inhaler
If you get into spasm and have a written protocol you will be more confident to handle
the bronchospasm. Multiple puffs of salbutamol inhaled properly without panic is the key to
reversing the spasm.
There are many other reasons for patients to stop inhalers inappropriately.
Inhalers are safe. Do not be in a hurry to stop them.
Doctors ought to hammer into patient the science and art of inhalers and disease.
Doctors ought to give written protocols to handle emergencies.
Lets win  Asthma , Let there never be an emergency and asthma related death. 

Wednesday, July 15, 2015

Immunotherapy in allergic diseases.

Conclusions of Allergy conclave.

  • Allergy is a global problem with ever growing prevalence.
  • While pharma co therapy is good for control of symptoms , immunotherapy is the only answer for disease modification.
  • For effective immunotherapy allergen identification should be accurate.
  • Accurate allergen identification depends on purified allergenic extracts , right technique and selection of subjects.
  • It is common to have multi-allergen sensitivity in a patient, in such situation most appropriate allergen need to be selected based on scientific evidence.
  •  Detailed history is most crucial in allergen identification correlation.
  • SPT is the preferred method of  allergy tests , SIgE may be necessary only in select situations and certainly remote testing just by  sending blood to some laboratory must be condemned.
  • Purified extracts  with standardized  biological value should be available to deal with this problem.

Thursday, April 30, 2015

collaborating as faculty for the 1st Allergo Conclave “Newer paradigms in Allergy Management” held on April 24, 2015.

 I collaborated as faculty for the 1st Allergo Conclave “Newer paradigms in Allergy Management” held on April 24, 2015.. Conclusions were very pertinent. 

Allergies are increasing worldwide , human airway disease is an immense economic burden globally.
Correct Allergen identification is of immense importance in planning treatment.
Detailed history is first important step. The history must focus on environment ,occupation,food and drug intake
by any route personal care products , meteorological and geographical variations etc, 
Skin prick test is the gold standard in tests if performed with purified allergens with correct technique.
Specific IgE is of value where skin tests are not possible but practice of just doing this in a lab without 
expert consultation must be condemned. Total IgE is nonspecific , associated with many other common conditions like parasitic infections , and is not recommended.
 Provocation tests , nasal and bronchial should be used to identify major allergens.
Food allergies also have an important role in respiratory allergies.
For Food Allergy double blind placebo controlled challenge test is gold standard.
Poli Sensitisation in different studies is from 27 to 78 percent in respiratory allergies..
Pharmacotherapy and Immunotherapy are methods of treatment.While inhaled steroid is the cornerstone in reducing inflammation, immunotherapy is useful in long term management.
Immunotherapy if done scientifically with purified allergen extracts, after accurate identification of major allergen can help in reducing doses of medicines and is steroid sparing .
Most important step is to select the  relevant allergen useful for Immunotherapy.
Relevant allergen is not the one which has maximum positivity on skin test but is the one which has maximum correlation with history and other factors.
European studies do not recommend mixing of allergens.
American studies do not recommend mixing of more than 4 allergens.
While mixing compatibility with each other and degradation of proteolytic enzymes must be considered.
Certain groups like fungi with dusts should never be mixed for immunotherapy.
It is preferable to give single allergens on two arms.
Subcutaneous immunotherapy ( SCIT) and sublingual immunotherapy (SLIT) are two methods in use.
Studies have  found SCIT to be superior but SLIT has the advantages of ease of home administration and no harmful effects like anaphylaxis.
Minimum duration of immunotherapy is 3 to 5 years.
Pharmacotherapy is useful in everyday management of patients but Immunotherapy is the only method by which long term disease modification is possible.
Immunotherapy has stood itself on firm scientific grounds , certainly helps in reducing symptom score and medication requirements. It also helps in preventing new sensitization. It stops the march of Allergic rhinitis towards Asthma development.
Health education is most important aspect for better compliance.

Monday, March 2, 2015

Posted By Claire Gagné On 2010/06/30 (7:59 pm) In Asthma
From the Allergic Living magazine archives.
FORGET the stereotype of the wheezy, wimpy kid puffing on an inhaler. Young athletes prove that you can be a winner in sports – even with asthma.
Since being diagnosed with asthma when he was 4 years old, Brett Favaro has suffered pneumonia and bronchitis, asthma attacks, and been to numerous doctors. Now 22, he still has a nebulizer, a machine that delivers asthma medication in a fine mist through a facemask, in his bedroom.
But if you’re picturing a skinny kid, wheezing on the sidelines, you’ve got the wrong guy. Favaro was a competitive swimmer for 13 years, culminating with a stint as captain of the varsity swim team at Simon Fraser University in Vancouver. He’s also competed in cross-country running, taken tae kwon do lessons, and played basketball. Plus, he’s an avid weightlifter. Favaro says that with the support of his doctor, “I was able to do everything that everyone else did. I just had to be more mindful of my ability to breathe than other people.”
Growing up, Favaro achieved what experts say is possible for all asthmatic kids. “If they have good control, they can be competitive to any level,” says Dr. Brian Lyttle, a pediatric respirologist in London, Ontario. Good control usually means taking a corticosteroid (such as Flovent or Pulmicort) every day to reduce inflammation, minimizing exposure to triggers such as cigarette smoke and allergens, and having a fast-acting reliever puffer on hand in case of an asthma attack.
While exercise is important for everyone, it plays a special role for people who have asthma. “The better shape you’re in, the better your lungs function,” says Dr. Michael Clarfield, a sports medicine specialist and former team physician for the Toronto Maple Leafs. “When you’re getting diminished function from your asthma, the more function you had to start with, the better off you will be.”
Dr. Alan Kaplan, a doctor in Richmond Hill, Ontario who chairs the Family Physician Airways Group of Canada, looks at it this way: “Exercising will teach your muscles to learn to work with what you’ve got. So even if you do have lung impairment, it’s still important to exercise and to teach your muscles to be able to exercise even at lower oxygen levels.”
It’s not that asthmatic kids should ignore their symptoms and push themselves into respiratory distress; rather, with the right combination of medications, and in a supportive environment with minimal triggers, all kids with the disease should be able to reach their athletic goals.
Katherine Smith, 14, a Canadian whose family lives in Phoenix, has certainly not let asthma deter her athletic pursuits. A bout with pneumonia at age 1 left her with diminished lung function, and she also has bad seasonal allergies. When she was about 9 years old, her parents noticed she had difficulty breathing when she ran or played sports at school. “If she had to do anything that required any endurance, all of a sudden she was gasping for air,” says her dad, Doug Smith.
With the right medications and a good attitude, Katherine has thrived. She pitches for a competitive softball team that placed ninth out of 70 teams at last year’s U.S. national championships. “She treats the asthma meds as something ‘I’ve just got to do to prepare,’ ” says Smith, “like going to conditioning class, or to her trainer.”
But not every kid with asthma is a Brett or a Katherine. There is growing evidence that some young people with asthma shy away – not just from team sports – but from physical activity period. Researchers at John Hopkins Medicine conducted a telephone survey of 243 parents in 2004 and discovered that 20 per cent of asthmatic children were not getting enough exercise.
The lack of activity stemmed partly from misguided beliefs: 25 per cent of parents surveyed with an asthmatic child were afraid their child would get sick if he or she exercised. The kids’ attitudes toward exercising also played a role: 25 per cent of the parents responded that their child gets “upset with strenuous activity”.
A study published in the Journal of Asthma in March 2008 compared overweight status in adolescents with and without asthma; the study authors found that receiving an asthma diagnosis in early childhood may increase the likelihood of becoming overweight. Kaplan relates that he has been approached by parents asking him to write a note dismissing their child from gym class. “There are people who use asthma as an excuse not to exercise.”
For parents who don’t know a lot about the disease, hearing that their child has asthma can be alarming. There’s often a lack of understanding of both the disease and the level of control that should be attainable. When Jordan Stewart of Thornhill, Ontario, was diagnosed at age 3, his mother Tula Stewart was terrified. “My heart just dropped,” she says. “I was devastated. You hear stories of people dying from it; that was probably my biggest fear.”