Allergy Advisor
 
Examples & Scenarios

In order to assist the reader with the practical application of Allergy Advisor, numerous scenarios have been outlined with the corresponding procedure on how to gain the maximum possible benefit from the knowledge and information contained in the program.

These scenarios have been designed to assist those readers who may not be familiar with the use of the program, or are not medically trained and/or are not experienced in the management of food adverse reactions.

Scan through the scenarios to find the one closest to the particular clinical case in which you are interested, or browse through them all to get a complete overview of the many ways in which the information in this program can be used in various clinical situations. The examples are to illustrate the principle of how Allergy Advisor can be utilised.

Examples/Scenarios
  1. Patient claims to be "allergic" or to react adversely to tomato

  2. Patient claims to be "allergic" to orange, but tests are negative

  3. Patient claims to have experienced a reaction to orange pips but not orange flesh.


Example 1.
Patient claims to be "allergic" to or to react adversely to e.g. tomato

Background
It should be explained to the patient that there are several mechanisms how they could be reacting adversely to tomato and it will be necessary to do some tests to confirm that they are indeed reacting adversely. As it is easiest to do either CAP RAST tests on blood or Skin Prick Tests then this (these) will be done first of all. A positive result with either will confirm the production of IgE by that patient's immune system against that food. This in turn will confirm sensitivity, which is most probably the cause of the symptoms. However, a negative result does not mean that the patient is not reacting adversely against the food, as tomato can cause an adverse reaction by any of several different pathways. For example, tomato contains many substances that the body may be reacting against, including pharmacologically (chemically) active substances.


The CAP RAST blood test and the Skin Prick Test only detect any IgE against a particular food involved in a true allergic reaction, but do not detect any other mechanisms, such as a chemical sensitivity. Information on alternative mechanisms and the identity of possible causative substances can be easily provided by the Allergy Advisor.


Action
Taking a history is always essential. If the symptoms are very strongly indicative of an allergy or the allergy tests are positive:

  1. On the Allergy Advisor Main Menu, click on "Items, Substances & Allergens"
  2. Type in "tomato" and then click on "Search", this will provide you with a list of all the foods containing the word "tomato".
  3. Select "tomato" by clicking on the word.
  4. This will provide you with a list of substances e.g. histamine, serotonin, asparagine, tomato, etc., that may be found in "tomato".
  5. Now click on "Tomato" in the list of substances present in tomato to see the reactions that have been experienced. Reactions described here are allergic in nature or other that occur and that cannot be attributed to any of the other substances listed.
  6. Confirm that the reactions described may be due to an allergy.
  7. If so, now close this window.
  8. Now click on the "Crossreactions" button in order to see what other foods the patient may be reacting to because of the presence of crossreacting allergic proteins, e.g., an individual reacting to "tomato" may also then react to eggplants, green peppers, potatoes and tobacco leaf.


Patient advice:
It should be explained that the reactions are in fact allergic in nature. You may need to follow the diagnosis with blood or skin tests if the diagnosis is still in doubt. Explain that foods containing tomato should be avoided but that cooked tomato will have its protein destroyed and may be able to be tolerated. Some tomato-allergic individuals may be allergic to other foods that have proteins that the body "sees" as being similar to that of tomato. Ask the patient whether she reacts to eggplants, green peppers, potatoes or tobacco leaf. If unsure, the patient should monitor these items for possible adverse reactions. If adverse reactions have been noted with a few, cross-reactions to all are very probable. Suspected reactions to other foods can be confirmed by further blood tests (CAP RAST) on the same blood sample or by further skin tests.


If the symptoms are not typically allergy-like or blood tests are negative, use Allergy Advisor to see if the symptoms experienced have been described as allergic in nature previously or look for other substances that may be causing the reactions. See example: "Patient claims to be "allergic" to orange, but tests are negative."

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Example 2.
Patient claims to be "allergic" to orange, but tests are negative

Background
There will be many occasions when a patient claims to be "allergic" to a particular food yet the results of the available blood tests or skin tests are negative. It should be explained to the patient that there are several mechanisms how you could be reacting adversely to a food. Firstly they need to understand that the CAP RAST blood test and the Skin Prick Test only detect IgE against a particular food and that the symptoms of apparent food allergy are in fact caused not by an allergic reaction to that substance (that involves IgE) but by some other mechanism. This information can be easily proven by the Allergy Advisor.


For example, the patient does not describe a true allergy-like reaction but complains of headaches when eating oranges, and possibly also with sauerkraut.


Action
Taking a history is always essential. If the symptoms are not very indicative of an allergy, or the allergy tests are negative:


  1. On the Allergy Advisor Main Menu, click on "Items, Substances & Allergens"
  2. Type in "orange" and ENTER, this will provide you with a list of all the foods containing the word "orange".
  3. Select "orange" by clicking on the word.
  4. This will provide you in the lower window with a list of substances present in orange e.g. Limonene, oxalate, orange etc that may be found in "orange".
  5. Select each substance individually by clicking on the name.
  6. Click on tyramine, one of the substances listed as found in orange.
  7. A new window opens with Tyramine listed in the substance window, and with a list of foods that may contain tyramine.
  8. Sauerkraut is listed as one of the foods containing tyramine.
  9. Click on "Substance Info", a window opens describing the various reactions seen with tyramine. Confirm that tyramine can cause headaches, and close this window.
  10. Clicking on "orange" brings up a window, which describes reactions that are allergic in nature, or other that occur and that cannot be attributed to any of the other substances listed.


Patient advice:
It should be explained that the reactions are in fact non-allergic in nature. It should be explained that tyramine is a substance occurring naturally in many foods, is a pharmacologically active substance (works like a drug), and which typically results in migraine. It should be explained that this is a dose dependent effect and thus side effects will appear depending on the amount of food eaten that contains this substance. The list of foods containing tyramine and to be avoided can be printed out and given to the patient.

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Example 3.
Patient claims to be have an allergic-like reaction to orange pips and not to orange flesh.

Background
There will be many occasions when a patient claims to be "allergic" to a particular food yet reactions described appear unusual. It should be explained to the patient that there are several mechanisms how they could be reacting adversely to a food and that there may be unusual patterns to the allergic reactions. Firstly they need to understand that the CAP RAST blood test and the Skin Prick Test only detect IgE against a particular food and that these tests can sometimes be negative in 5-40% of individuals, depending on the food and the individual. This information can be easily proven by the Allergy Advisor.


Action
Taking a history is always essential. If the symptoms are very indicative of an allergy, and the allergy tests are negative, this may still be an allergy:


  1. On the Allergy Advisor Main Menu, click on "Items, Substances & Allergens"
  2. Type in "orange" and ENTER, this will provide you with a list of all the foods containing the word "orange".
  3. Select "orange" by clicking on the word.
  4. This will provide you in the lower window with a list of substances present in orange e.g. Limonene, oxalate, orange etc that may be found in "orange".
  5. Clicking on "orange" brings up a window, which describes reactions that are allergic in nature, or other that occur and that cannot be attributed to any of the other substances listed.
  6. An article describing a previous case of an individual reacting with an allergy reaction to orange pips and not orange flesh confirms that this is possible.


Patient advice:
It should be explained that the reactions are in fact allergic in nature. It should be explained that it the level of protein in oranges are variable and changes with the type of orange and the age of the orange and that protein levels are higher in orange pips. A true allergic reaction to orange pips may result in a true allergy to orange depending on these factors and thus one should have a high level of awareness for further reactions that may occur with orange itself. The patient may be better off avoiding all orange products except cooked or heat processed orange products as the protein is heat labile.

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General Example

For example, a patient presents with a complaint of reactions after eating salad. She regularly eats a restaurant salad consisting of lettuce, olives, avocado, carrots, and oil and vinegar dressing, and lately after eating this salad she has had a prickly sensation around the mouth, a tight chest and gastrointestinal symptoms. She thinks she may be reacting to a food, but to what?


Her doctor, dietitian or nutritionist can enter each of the ingredients of the salad in the first window of the Allergy Advisor program. For each of the ingredients, a list of component substances and typical reactions to them can be found. After a short search, the medical practitioner finds that the patient is most likely suffering from an allergy to avocado.


Allergies to a single food are uncommon, so the practitioner now wants to question the patient about any other experiences of reactions. The range of likely allergy can be narrowed down with the help of Allergy Advisor. The practitioner clicks on the Family button, and discovers that bay leaf and cinnamon are in the same family. The patient thinks she may react to bay leaf, as she has had slight similar reactions to soups and stews, without knowing the cause. To her knowledge, she has not eaten cinnamon in a long time, but wonders if she now should avoid it. But she asks how she could be sure of avoiding cinnamon; she has noticed that many processed foods do not list spices individually on the label, but only use the word "spices" or "natural flavourings," or similar words. How can she know what processed foods to avoid, if she does need to avoid cinnamon? A short search in Allergy Advisor shows, among other unexpected sources of cinnamon, barbecue sauce, sausages and even some cosmetics. At this point, the patient draws attention to a slight rash on her scalp that has been bothering her for several weeks. Could her "herbal" shampoo be at fault? she wants to know.


A large percentage of people who react to members of one food family also react to certain members of other families. A patient reacting to avocado may also react to banana, chestnut and latex, and these possibilities would need to be explored in the case of the patient described above. Some allergies can be debilitating or even life-threatening, and most change over time, so it is dangerous to take a trial-and-error or "wait and see" approach after a single allergy has been diagnosed.


Another patient, with a history of asthma, eats salad both in restaurants and at home. The salads at home he makes from vegetables he grows himself. What puzzles him is the severe asthmatic reactions he sometimes experiences after eating restaurant salads. The medical practitioner immediately suspects that the patient is sensitive (as opposed to allergic) to some additive or preservative, as no visible ingredient of a typical salad seems to be to blame. A search through Allergy Advisor reveals that sulphur dioxide is the likely culprit, and the patient would need to be advised to avoid restaurant and grocery-store salad altogether, as sulphur dioxide is widely used as a commercial preservative of vegetables, particularly of greens. Allergy Advisor can also show other unexpected sources of sulphur dioxide, including dried fruit.


In these ways, Allergy Advisor can greatly simplify the approach to allergy testing and dietary and lifestyle planning, which in the past required specialised knowledge that was not part of a typical medical education.

 

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