Atopic keratoconjunctivitis

Dermot was a fifteen-year-old schoolboy with several years of itchy, watering eyes. He also had a history of rhinitis and asthma. His eyes remained itchy in spite of anti-allergy eye drops and antihistamine tablets. His only relief came about by vigorously rubbing the eyes. His action was quite classical: he would press his curled index finger over his closed eye, and rub in a circular motion. And I mean rub! The eye surgeon diagnosed atopic keratoconjunctivitis with corneal deformity. His cornea had lost its nice smooth dome-shaped appearance, and looked more like the oval end of a rugby ball! We call this conical deformity 'keratoconus'. Dermot now needed a corneal graft (and here's one more good reason to sign your donor card!); without a healthy cornea from a donor eye, he would go blind. But how would a graft survive all this rubbing? The eye surgeon referred him to the Allergy Clinic for help with the allergic aspects of his disease. From the history, we suspected that certain airborne allergens were making him worse: house dust, animal danders, feathers and grass pollen all made his eye intensely itchy. He also noticed that perfumes, and the like, could aggravate his symptoms. Having confirmed his allergies by skin tests, we started him on a course of desensitisation. He has had four injections over the past eight months and his symptom are much better controlled. Specifically, the itch and the rubbing have ceased, and the surgeon is now ready to proceed with the graft.



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Non-allergic triggers of conjunctivitis

In common with other allergic diseases (such as eczema, rhinitis and asthma), allergic conjunctivitis may be aggravated by non-allergic triggers. Failure to understand this could lead to many a wild-goose chase. Maureen was one such patient. She had moved into the area some three years earlier, and since doing so developed 'hay fever' symptoms. Her most troublesome symptom was watering of the eyes, but she also had rhinitis. Her symptoms were particularly bad whenever she went outdoors during the summer months. She was convinced that something in the air was affecting her. However, the skin tests failed to show a relevant summer allergy. She was not allergic to any of the pollens. Nor was she allergic to mould. Her only positive reaction was to our old friend, the house dust mite. This didn't fit with her expectations, and she remained convinced that 'we were missing something'. Going back into her history, she told me that her eyes were especially bad on bright, windy days. 'Maybe it's the silage, or the fertiliser being spread by neighbouring farmers,' she thought out loud, 'They never did that near my last house, you know.' Maureen had an allergic conjunctivitis and rhinitis related to the house dust mite. Her 'seasonal exacerbations' were in fact the result of non-allergic triggers: the combination of wind and sunlight. Other non-allergic triggers include inert dusts, such as chalkdust and the chemical vapours commonly found in household products.

Are there any complications?
Allergic conjunctivitis is a miserable condition. It can disrupt academic performance and summer holidays, and impair the overall quality of life. It can be particularly nasty when associated with eczema, because it may affect the cornea, the transparent part of the eye through which we see the outside world. Allergic inflammation of the cornea can result in scarring, ulceration, cataract formation and corneal deformity. We call this 'atopic keratoconjunctivitis': atopic referring to the allergic disposition, and kerato- referring to the corneal involvement.



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Oral Allergy Syndrome Case History

It all started two years ago for Caroline. She was eleven years old when she first noticed that something was amiss. Her mouth went numb and her upper lip swelled after eating melon. It passed of its own accord, she shrugged her shoulders and forgot about it. Two months later she had a similar experience, this time with an apple. Her lips and tongue felt ‘funny’, a bit numb, or maybe there was a slight tingle (she found it hard to describe). Within weeks, she was reacting in this way to carrots, peppers, lettuce, kiwi and cherries. By the time I saw her, she had stopped eating all fruit and vegetables. However, she discovered that if these foods were cooked first they caused her no trouble — except, perhaps, for carrot. Of some concern was the fact that she was now likely to get chest pain and shortness of breath if she inadvertently ate a forbidden food, such as when she visited a friend and the vegetables were cooked al dente (slightly raw, the way they should be). She denied any other allergic history, and this is the only unusual aspect of her case. On skin-testing she reacted as expected to silver birch pollen (see below). She also had positive skin tests to egg, potato, peanut, soy bean, orange, strawberry, pear, banana, lemon, coconut, grape, peas, tomato and onion! I gave up testing her at that stage, and I did a blood test to confirm that the skin tests were truly positive, and not just a quirk of her funny skin, or my imagination! Every single blood test came back positive. On blood test, she was allergic to all of the foods mentioned above, but she was also positive to grass pollen and mould! Caroline had a classical case of Oral Allergy Syndrome.



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An example of contact allergic conjunctivitis

Mrs. Neary was a middle-aged woman used to a good social life. As such, she had frequent cause to 'make herself up', and very glamorous she was too! She knew that cheap jewellery gave her a rash, but that didn't bother her because she didn't like cheap jewellery anyway. She was bothered by a recurrent rash on her eyelids, though. She couldn't understand it, having never suffered from the like before. Patch tests confirmed her sensitivity to nickel, but they also revealed a problem with one of her favourite moisturisers. It contained avocado, and she had become allergic to it. 'But I've used it for years!' she protested. (You've heard it all before, right?) She had sensitised herself to it over time. 'But why are my hands not affected then?' she persisted. 'Because the skin over your eyes is only 0.55 mm thick, and it's very delicate, that's why!' All she had to do now was avoid the offending allergen. She should also be careful not to handle nickel (coins, keys, cutlery, etc.) as this could contribute to periorbital dermatitis as well.

The outcome is not always so clear for patients with suspected cosmetic allergy. Some unfortunates have 'status cosmeticus' — a non-specific irritation to virtually all cosmetics. To confound matters, they may have no outward sign of irritation or allergy, but they complain of burning or stinging whenever they wear cosmetics. Some of them will have slight redness over the cheeks, with or without slight swelling of the eyelids, but nothing more substantial than this. Treatment? Avoid all cosmetics!



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A few examples of asthma triggered by foods

Kevin was a four-year-old boy plagued with allergies. Mum and Dad knew that he was allergic to eggs. They made him extremely ill. Within ten minutes of eating them he would break out in a rash of hives and vomit violently. He also had eczema, asthma and rhinitis. Finally, and this is the reason his parents brought him to the Allergy Clinic, he had become hyperactive in recent months. 'He was always an active child,' they said. 'But this is ridiculous! He gets mood swings, loses his temper, and disrupts his Montessori class.' We put him on the Low Allergy Diet in the hope of improving his mood and behaviour. He enjoyed great relief from all his symptoms within ten days of his diet. 'His mood is much lighter, and he is now so pleasant,' his parents told me. 'Not only that, but his asthma, eczema and rhinitis are better than they have been for years.' Asthma can be triggered by allergy to food — particularly when other symptoms of food allergy are present!

Bernard was a little older than Kevin when I first met him. He also had a long history of asthma, and he too had other symptoms of food allergy. In particular, he frequently complained of bellyache and headache. Every day, he took two inhalers and one tablet to control his asthma. Notwithstanding his medication, he had a constant cough. In addition, he had several bad attacks each year requiring treatment with steroids. We put him on a ten-day Low Allergy Diet. By day seven, his lung function had improved quite dramatically. We then set about expanding his diet again, and managed to reintroduce all major food items without incident — until we came to soft drinks. Within thirty minutes of drinking a well-known branded lemon drink he developed an acute asthmatic attack. The drink was laden with metabisulphite — a preservative, and a recognised problem for some asthmatics. Asthma can be triggered by an allergy to food additives!



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A few examples of asthma triggered by inhalant allergy

Nuala is a housewife and mother of two. She has been very unwell in recent years with asthma. She also had repeated sinus and chest infections. Furthermore, she was admitted to hospital on two occasions with pneumonia, and once to have her nasal polyps removed. Not surprisingly, some concern was expressed about the state of her immune system. Skin tests were interest­ing, to say the least. She was highly sensitive to house dust mites and grass pollen, moderately sensitive to several mould species (Aspergillus, Alternaria, Candida, etc.), and mildly react­ive to dog. She then told me that her home was an environmen­tal disaster area! They had problems with rising damp, and the wine cellar (they had a wine cellar!) was very damp and musty. As it happens, they were about to move house anyway, so they paid particular attention when looking at new property to avoid mouldy conditions. She improved dramatically within weeks of the move, and remains well at the time of writing (three years later). Asthma can be triggered by mould allergy!

Bartley is an accountant who loves to forget about it all on horseback in an open field. So he was particularly upset to realise that he was starting to wheeze every time he went near his horse. He was perfectly well at other times. Skin tests con­firmed his allergy: within ten minutes of scratching his arm with horse allergen he produced an enormous response. He was not allergic to anything else. Horse allergen is a potent one, and it is capable of triggering a severe and rapidly progressive asthmatic attack. Asthma can be triggered by animals!

John Hamilton was Archbishop of St Andrews in the sixteenth century. He had asthma. He also had a lot of money. Displeased with local treatment, he called for a renowned physician, Jerome Cardan of Pavia. Jerome travelled from Italy to Scotland with nothing much more than his bag. He took one look at the sorry priest puffing and wheezing in his bed. 'Get rid of that feather quilt!' he exclaimed, turned on his heel and returned to his lodg­ings. This may have been the shortest consultation in history, but the cleric's recovery was so complete that he rewarded the good doctor with 1,400 pieces of gold, and a gold chain for his neck. Asthma can be triggered by an allergy to feathers!



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Case history for airborne allergies

Adrian is a thirteen-year-old boy who loves sport. He has suffered from asthma since early childhood. He was taking three different inhalers every day, and was still getting symptoms. Moreover, he was waking up in the early hours of the morning for 'a few more puffs' of his inhaler. When things got out of hand, and they did several times a year, he needed oral steroid tablets. In addition, he occasionally had really bad attacks requiring admission to hospital. These were mostly associated with infection. His family doctor wondered whether there was an allergic aspect to his asthma and referred him to the Allergy Clinic. Adrian said that he manages to get by if he 'takes things easy'. But he was a sportsman, and did not want a sedentary lifestyle. He was very frustrated by his inability to ran without coughing and wheezing. Taking his inhaler before a football match did not help. He also had hay fever — and a cat!

Skin tests revealed that he was highly allergic to many airborne allergens, including pollens, dust mites and moulds. He was also allergic to the cat. The first job was to clean up his home environment. He went to town on this, and adopted comprehensive allergen avoidance measures. He asked someone else to adopt the cat. His asthma improved within weeks, but he still had some way to go. We then started a course of desensitisation. By the time of his fourth dose, his lung function had improved considerably, he was sleeping through the night, he played football for the school team, and he had enjoyed a summer without hay fever. We are now weaning him off his inhalers.



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A few examples of asthma triggered by inhalant allergy

James was eight years old when he first came to the Allergy Clinic. His history is quite classical and demonstrates much of what you have just read. In the first place, he came from an allergic family. His mother and several cousins had a history of hay fever. He himself had a history of eczema as a baby, but this had cleared up long ago. 'He's sneezing and wheezing!' his father said. 'And he coughs. Boy, does he cough, especially at night when we're all trying to sleep! He was taking the usual inhalers but still getting into trouble. Like most asthmatic children, he got a bit of a wheeze when he ran about. His father, unfortunately, was a chain-smoker, and this was sure to make things worse. Skin-prick tests showed that James was allergic to the ubiquitous house dust mite, and had a lesser sensitivity to silver birch pollen. His father promised to smoke only in the back garden, and he took careful note of the measures required to reduce the dust mite allergen in James's bedroom. The boy then had one dose of desensitisation and improved so dramatically that his mother thought he was 'cured'! However, it wore off after a few months (as expected) and he is now well into his course of jabs and on the road to more permanent relief. Asthma is often triggered by the house dust mite!

Declan was a businessman in his late thirties. He had asthma as a young lad for a few years and then grew out of it. However, it came back to him last autumn, together with the symptoms of rhinitis. It wasn't particularly bad, he said, more of a nuisance than anything else. Again, skin tests confirmed his allergy to dust mites. He had no other allergy. Desensitisation brought about a great improvement. The last time I saw him for a booster dose he told me that he had stopped his inhalers altogether. Asthma in adults can also be triggered by house dust mites!

Helen is a university student coming up to her summer exams. She is 'really fed up today' because she has asthma. In fact, she tells me that she gets asthma at this time every year, and it interferes with her study. She also gets the other symptoms of hay fever. Once the summer holidays are over, she has no asthma. Skin tests confirm her allergy to grass pollen, and the fact that she is not allergic to other allergens. She has 'hay asthma1. Asthma is sometimes triggered by seasonal allergens!



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Allergic rhinitis: case study

Ciara is a ten-year-old girl. 'She has had one cold after another for the past two years,' her mother said. I asked her what she meant by that. 'She is always getting sore throats and sore ears, she sniffs all the time, and she can't breathe through her nose,' she explained. The child was the portrait of misery. 'And look!' she continued, pointing to the girl's upper lip, 'She has the skin of her face rubbed raw with tissues.’ It did not take long to hazard a guess at the problem: the lining inside Ciara's nose was inflamed. It looked an angry blood-red. There was also a copious nasal discharge of clear mucus, like raw egg white. Her turbinates were swollen to the point of obstructing both nostrils. She was breathing through her mouth. In addition, one ear was full of fluid, as could be seen through a lacklustre eardrum. Skin tests revealed that Ciara was highly allergic to house dust mites, grass pollen and some moulds. Ciara has, until proven otherwise, an allergic rhinitis.

Let's take a closer look at Ciara's symptoms. The inflammation in her nose was causing rhinorrhoea and obstruction. The obstruction was blocking one of her Eustachian tubes, allowing an accumulation of fluid in the middle ear on that side. The resultant pressure in her ear was painful. Nasal obstruction was also causing her to breathe through her mouth, and this was drying her throat excessively, particularly during sleep. It was no wonder she had sore throats. Furthermore, because she couldn't breathe easily, her sleep was bound to be disrupted, contributing to her tiredness and misery.



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Case study for Allergy Clinic

CASE HISTORY

Ten-year-old Dermot was referred to the Allergy Clinic because he had an intensely itchy rash. It first appeared in infancy, when he was just four months old. At the time only his face was affected, and he was successfully treated with medicated creams prescribed by his doctor. As he got older the rash reappeared, and spread to other parts of his body, including his neck, arms, legs and ankles. The rest of his skin, although not directly affected by rash, was dry and flaky. In recent months his rash had worsened considerably, and his ferocious scratching had left him with large areas of broken and weeping skin. He was in pain. He was also miserable because the itch had disrupted his sleep for weeks, and because his peers at school were now teasing him about his appearance. Dermot has eczema.

Roisin was a 35-year-old nurse and she had developed a peculiar rash. It was odd only because of where it was: one big patch on the right side of her neck just below the ear, and another on the outer aspect of her left arm. Nowhere else was affected. The rash had been present for many months, and she had tried several creams with varying degrees of success. She was puzzled by its persistence. ‘Do you always sit like that?’ I asked. ‘Like what?’ She said. ‘With your right hand tucked in under your chin one minute, and stroking the side of your left arm the next!' She did always sit like that, and when I advised her to stop wearing nail varnish, the rash disappeared. Roisin had contact allergic dermatitis. In her case it was an allergy to something in the nail varnish.



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