Allergy Power Point Presentation

ALLERGY ALLERGY CARECARE

ALLERGY & ASTHMA CAREALLERGY & ASTHMA CARE ----------------------------------------------------------------------------------------------------------------

ALLERGEN DIAGNOSTIC WINGALLERGEN DIAGNOSTIC WING

DR RAJIV PATHLAB DR RAJIV PATHLAB ALLERGY ASSAY & IMAGING CENTREALLERGY ASSAY & IMAGING CENTRE

BY BY SERUM BASED SERUM BASED EASTEAST (Enzyme Allergo Sorbent Test)(Enzyme Allergo Sorbent Test)

Allergy DiagnosticsAllergy Diagnostics

The Handbook of Allergy DiagnosticsThe Handbook of Allergy Diagnostics

Dr. Rajiv Path Lab with your co-operation is constantly evolving and innovating diagnostic Dr. Rajiv Path Lab with your co-operation is constantly evolving and innovating diagnostic organization dedicated to setting and meeting exacting needs of laboratory diagnostics, for the organization dedicated to setting and meeting exacting needs of laboratory diagnostics, for the immunodiagnosis of thyroid and fertility hormones, cancer markers, diabetes marker, immunodiagnosis of thyroid and fertility hormones, cancer markers, diabetes marker, infectious diseases assay, autoimmune diseases, HLA markers, Hba1c microalbumin, CRP, infectious diseases assay, autoimmune diseases, HLA markers, Hba1c microalbumin, CRP, lipid testing, basic clinical chemistry panel, allergy diagnostics and clinical lipid testing, basic clinical chemistry panel, allergy diagnostics and clinical pathology,electrophoresis, Cardio-pathological and imaging(radiodiagnosis)pathology,electrophoresis, Cardio-pathological and imaging(radiodiagnosis)

which are managed by qualified and deserving professionals, un-interfering & independent which are managed by qualified and deserving professionals, un-interfering & independent faculties. faculties.

The aforesaid objectives can only be achieved through:The aforesaid objectives can only be achieved through:

The application of state –of –the- art technologies to the services that we make available.The application of state –of –the- art technologies to the services that we make available. Interfacing with our esteemed doctors on the technical and procedural aspects of the Interfacing with our esteemed doctors on the technical and procedural aspects of the

techniques required by them.techniques required by them. We are indeed glad to launch an additional wing to add up to the services provided to you.We are indeed glad to launch an additional wing to add up to the services provided to you. What is Allergy ?What is Allergy ? An allergy is an abonormal reaction or increased sensitivity to certain substances. It is the An allergy is an abonormal reaction or increased sensitivity to certain substances. It is the

collective name given to a wide spectrum of clinical conditions. They are all caused by collective name given to a wide spectrum of clinical conditions. They are all caused by overproduction of an antibody (a special protein) called immunoglobulin E (or lgE) by the overproduction of an antibody (a special protein) called immunoglobulin E (or lgE) by the body’s immune system.body’s immune system.

““Up to 30% of all visits to General Practitioners or Paediatric Specialists are because of allergy.”Up to 30% of all visits to General Practitioners or Paediatric Specialists are because of allergy.”

It is becoming more common because of It is becoming more common because of increasing urbanization and changes in diet increasing urbanization and changes in diet and lifestyle. It is important to use the term” and lifestyle. It is important to use the term” allergy” correctly. It is incorrect to use it allergy” correctly. It is incorrect to use it where lgE is not involved. This is especially where lgE is not involved. This is especially true for so-called”food allergy.”true for so-called”food allergy.”

AllergensAllergens

ALLERGENSALLERGENS Substances that cause allergies are called “allergens” Over 700 Substances that cause allergies are called “allergens” Over 700

environmental allergens have been identified, characterized environmental allergens have been identified, characterized and purified. These are important for a modern approach to and purified. These are important for a modern approach to diagnosis nand treatment of allergies. Differentiation must be diagnosis nand treatment of allergies. Differentiation must be made between different allergens whose amino acid sequience made between different allergens whose amino acid sequience has been completely established.has been completely established.

Important Allergen GroupsImportant Allergen Groups GroupAllergenIndoor AllergensHouse Dust GroupAllergenIndoor AllergensHouse Dust

MiteCatDogCockroachesOutdoor AllergensTree pollenGrass MiteCatDogCockroachesOutdoor AllergensTree pollenGrass &Grain PollenHerbs, WeedsFoodChicken Egg WhiteCow’s &Grain PollenHerbs, WeedsFoodChicken Egg WhiteCow’s MilkPeanutsSeafoodInsect MilkPeanutsSeafoodInsect VenomsBeesWaspsMoldsAlternariaCladosporiumAspergillusVenomsBeesWaspsMoldsAlternariaCladosporiumAspergillus

SCREEN BENEFITS FOR DRSSCREEN BENEFITS FOR DRS Allergy Screen(serum based) benefits you by:Allergy Screen(serum based) benefits you by: Facilitating allergy assessment, diagnosis and a long lasting Facilitating allergy assessment, diagnosis and a long lasting

patient relief. patient relief. Treat your allergy patients by further counseling and your Treat your allergy patients by further counseling and your

follow up whenever needed.follow up whenever needed. Quick, easy access to the latest allergen information and peer-Quick, easy access to the latest allergen information and peer-

reviewed notes with every report. reviewed notes with every report. Keeping yourself informed and educating your patient at your Keeping yourself informed and educating your patient at your

clinic once the report reaches you the same day.clinic once the report reaches you the same day. Gives you an additional wing of “treatment based allergy Gives you an additional wing of “treatment based allergy

care” at your clinic.care” at your clinic.

APPROACHAPPROACH TARGET BASED APPROACH NEEDED FOR MAXIMUM RESULT TARGET BASED APPROACH NEEDED FOR MAXIMUM RESULT

ORIENTATION WITH MINIMUM PATIENT DISCOMFORT.ORIENTATION WITH MINIMUM PATIENT DISCOMFORT. Q: IS IT ALLERGY?Q: IS IT ALLERGY? Is it allergy?Is it allergy? EczemaEczema

1 out of 3 infants and young children with eczema has underlying allergy and may 1 out of 3 infants and young children with eczema has underlying allergy and may benefit from a diet or other form of avoidance - which ones are they? Persistent benefit from a diet or other form of avoidance - which ones are they? Persistent symptoms should always be tested.symptoms should always be tested.  

RhinitisRhinitisUp to 7 out of 10 children and many adults with seasonal and perennial rhinitis are Up to 7 out of 10 children and many adults with seasonal and perennial rhinitis are allergic and may benefit from differential diagnosis and treatment.allergic and may benefit from differential diagnosis and treatment.  

Wheeze/AsthmaWheeze/Asthma1 out of 3 preschool children and 2 out of 3 school children with recurrent 1 out of 3 preschool children and 2 out of 3 school children with recurrent wheezing/coughing are allergic and may benefit from allergy screen and treatment.wheezing/coughing are allergic and may benefit from allergy screen and treatment.

Similar figures are also applicable to adultsSimilar figures are also applicable to adults..

VARITIESVARITIES Allergy TermsAllergy Terms Atopy : Genetic ;predisposition to develop allergic (Type 1)DiseaseAtopy : Genetic ;predisposition to develop allergic (Type 1)Disease Sensitization : activation of the immune system with development of allergen specific lgE antibodies.Sensitization : activation of the immune system with development of allergen specific lgE antibodies. Allergy : clinical manifestation of an allergic disease as a result of allergic sensitization.Allergy : clinical manifestation of an allergic disease as a result of allergic sensitization. Common AllergiesCommon Allergies Allergic reactions or diseases may involve any part of the body: the most frequently involved are the nose Allergic reactions or diseases may involve any part of the body: the most frequently involved are the nose

and chest with resultant symptoms of hay fever rhinitis or asthma, respectively. The skin and deyes also and chest with resultant symptoms of hay fever rhinitis or asthma, respectively. The skin and deyes also commonly show allergic symptoms. Anaphylactic shock is a severe allergy, which affects many organs at commonly show allergic symptoms. Anaphylactic shock is a severe allergy, which affects many organs at the same time causing a rapid decrease in blood pressure, fainting and, occasionally, death. Such a the same time causing a rapid decrease in blood pressure, fainting and, occasionally, death. Such a reaction, though, is rare.reaction, though, is rare.

Hay feverHay fever The pollens of grasses, weeds and trees are the main causes of this type of allergy, although mold spores The pollens of grasses, weeds and trees are the main causes of this type of allergy, although mold spores

can also cause the symptoms. The lining of the nose becomes swollen and exudes a runny discharge. Spells can also cause the symptoms. The lining of the nose becomes swollen and exudes a runny discharge. Spells of sneezing and itchiness of the throat and palate a;so occur and the eyes may be similarly affected. of sneezing and itchiness of the throat and palate a;so occur and the eyes may be similarly affected. Depending on location and the pollinating periods, attacks may occur in spring, summer or autumn.Depending on location and the pollinating periods, attacks may occur in spring, summer or autumn.

Perennial Allergic RhinitisPerennial Allergic Rhinitis The symptoms are similar to hay fever but appear all the year round . This condition is caused by non The symptoms are similar to hay fever but appear all the year round . This condition is caused by non

seasonal allergens such as house dust components and certain molds.seasonal allergens such as house dust components and certain molds. EYE ALLERGY (CONJUNCTIVITIS)EYE ALLERGY (CONJUNCTIVITIS) Allergic conjunctivitis is often associated with allergic rhinitis. A general complaint is of itchiness of the Allergic conjunctivitis is often associated with allergic rhinitis. A general complaint is of itchiness of the

eyes, which are rubbed frequently.eyes, which are rubbed frequently.

?ASTHMA OR ALLERGY?ASTHMA OR ALLERGY AsthmaAsthma

TheThe asthmatic attacks obstruct the flow of air to the lungs. Breathing becomes diffcult and forced breathing becomes necessary. A wheezing sound can appear, due to the rush of air through the narrowed airways. At the same time, a troublesome cough can develop. Asthma may asthmatic attacks obstruct the flow of air to the lungs. Breathing becomes diffcult and forced breathing becomes necessary. A wheezing sound can appear, due to the rush of air through the narrowed airways. At the same time, a troublesome cough can develop. Asthma may

begin at any age and, if neglected, tends to recur and become chronic.begin at any age and, if neglected, tends to recur and become chronic. EczemaEczema The skin can become irritated and develop rashes that can be either wet or dry. The reactions are often accompanied by severe itching. The cause is often not clear, but is frequently seen in children of families with a history of allergic diseases. The eczema may start during the first The skin can become irritated and develop rashes that can be either wet or dry. The reactions are often accompanied by severe itching. The cause is often not clear, but is frequently seen in children of families with a history of allergic diseases. The eczema may start during the first

year of life, on the face. Later, it is often seen on the inside of the elbows and backs of knees, on the neck, ankles, wrists and on the back of the hands. It is possible for eczema to become secondarily infected with skin bacteria, especially if there is much broken skin due to year of life, on the face. Later, it is often seen on the inside of the elbows and backs of knees, on the neck, ankles, wrists and on the back of the hands. It is possible for eczema to become secondarily infected with skin bacteria, especially if there is much broken skin due to scratching.scratching.

Urticaria, Hives (Neetle rash)Urticaria, Hives (Neetle rash) This reaction appears very suddenly. The skin becomes warm, reddish and itching. The symptoms may last either for a couple of hours or up to a whole day. Blotches may appear as raised wheals and vary in size from smaller than a mosquito bite to several inches in diameter.This reaction appears very suddenly. The skin becomes warm, reddish and itching. The symptoms may last either for a couple of hours or up to a whole day. Blotches may appear as raised wheals and vary in size from smaller than a mosquito bite to several inches in diameter. In 95% of hives, the cause is unknown.In 95% of hives, the cause is unknown. Contact Dermatits Contact Dermatits The symptoms of contact dermatitis is similar to Hives, but this reaction is of another type. The cause is direct contact with different substances, such as:The symptoms of contact dermatitis is similar to Hives, but this reaction is of another type. The cause is direct contact with different substances, such as: Nickel (in coins, stainless steel, clasps, jewelry)Nickel (in coins, stainless steel, clasps, jewelry) Rubber products(in gloves, boots, waistbands)Rubber products(in gloves, boots, waistbands) Chromium (in cement, leather)Chromium (in cement, leather) LatexLatex Preservatives(in creams, ointments and cosmetics)Preservatives(in creams, ointments and cosmetics) This condition, unlike those listed above, is not due to the production of lgE antibodies, but is due to a different kind of immune reaction. It is usually due to increased sensitivity to a substance that a particular body part contacts.This condition, unlike those listed above, is not due to the production of lgE antibodies, but is due to a different kind of immune reaction. It is usually due to increased sensitivity to a substance that a particular body part contacts. Food AllergyFood Allergy Food Allergy Food Allergy Food allergy means that body reacts to certain foods. It is also called food hypersensitivity. Common symptoms are itching and burning around the mouth, asthma and vomiting. About 90 per cent of allergies are caused by nuts, eggs, milk or soy. Food allergies are on the increase Food allergy means that body reacts to certain foods. It is also called food hypersensitivity. Common symptoms are itching and burning around the mouth, asthma and vomiting. About 90 per cent of allergies are caused by nuts, eggs, milk or soy. Food allergies are on the increase

in our region and in India as a whole. in our region and in India as a whole. Food allergy causes the body to mount an immune response against the food. Symptoms include: Food allergy causes the body to mount an immune response against the food. Symptoms include: Breathing difficulties, including wheezing and asthma Breathing difficulties, including wheezing and asthma Fatal anaphylaxis Fatal anaphylaxis Itching, burning and swelling around the mouth Itching, burning and swelling around the mouth Nausea, vomiting, abdominal cramps and diarrhea or costipationNausea, vomiting, abdominal cramps and diarrhea or costipation Generalised urticaria - skin becomes red and raised,hives.Generalised urticaria - skin becomes red and raised,hives. About 90 per cent of allergies are caused by nuts, eggs, milk or soy. Food allergies are on the increase in our region and in India as a whole. About 90 per cent of allergies are caused by nuts, eggs, milk or soy. Food allergies are on the increase in our region and in India as a whole. Food allergy causes the body to mount an immune response against the food. Symptoms include: Food allergy causes the body to mount an immune response against the food. Symptoms include: Important food allergensImportant food allergens GroupImportant Allergens/ ComponentsChicken egg whiteOvalbumin, Ovamucoid, Conalbumin, LysozymeCow’s milkCasein, Lactalbumin, LactaglobulinSoya beansNutsHazelnuts(Filberts), Walnuts, Brazil nuts, Peanuts(Shelled nuts)Seafood (Fish)Fresh water, Salt water GroupImportant Allergens/ ComponentsChicken egg whiteOvalbumin, Ovamucoid, Conalbumin, LysozymeCow’s milkCasein, Lactalbumin, LactaglobulinSoya beansNutsHazelnuts(Filberts), Walnuts, Brazil nuts, Peanuts(Shelled nuts)Seafood (Fish)Fresh water, Salt water

fishGrainWheat, RyeVegetablesPotatoes, Celery, Tomatoes, Peas, BeansDyesTartrazinePreservativesSorbic acid, Benzoic acidOrganClinical PresentationGeneralizedAnaphylactic ShockSkinAtopic Dermatitis, UrticariaRespiratory TractRhino- Conjunctivitis, Laryngeal edema, fishGrainWheat, RyeVegetablesPotatoes, Celery, Tomatoes, Peas, BeansDyesTartrazinePreservativesSorbic acid, Benzoic acidOrganClinical PresentationGeneralizedAnaphylactic ShockSkinAtopic Dermatitis, UrticariaRespiratory TractRhino- Conjunctivitis, Laryngeal edema, AsthmaGastrointestinal Abdominal Pain, Nausea, vomiting, Constipation, DiarrheaOtherOtitis Media, Arthritis, MigraineAsthmaGastrointestinal Abdominal Pain, Nausea, vomiting, Constipation, DiarrheaOtherOtitis Media, Arthritis, Migraine

Insect AllergyInsect Allergy Severe allergic reactions to bee and wasp stings are not uncommon. The local toxoc reaction and discomfort that usually occurs following an insect sting is not generally considered to be allergic. lgE mediated(allergic) reactions induce symptoms such as nettlerash (urticaria, hives), Severe allergic reactions to bee and wasp stings are not uncommon. The local toxoc reaction and discomfort that usually occurs following an insect sting is not generally considered to be allergic. lgE mediated(allergic) reactions induce symptoms such as nettlerash (urticaria, hives),

running nose and eyes, swelling of the throat, attacks of asthma and, in severe cases, fainting.running nose and eyes, swelling of the throat, attacks of asthma and, in severe cases, fainting. Occupational AllergyOccupational Allergy The term occupational allergy is generally used to describe episodes of allergic reactions occurring after working with industrial dusts, vapors, gases of fumes, furthermore, substances like nickel (in coins), chromium (in cement), rubber, different dyes, formaldehyde and glues may The term occupational allergy is generally used to describe episodes of allergic reactions occurring after working with industrial dusts, vapors, gases of fumes, furthermore, substances like nickel (in coins), chromium (in cement), rubber, different dyes, formaldehyde and glues may

result in eczema that occurs at the site of contact with the skin. Inhalants such as grain dust may affect farmers. The degree of eczema depends on the length of exposure and sensitivity to the substance. Symptoms may show within some weeks but it can often take months, years and result in eczema that occurs at the site of contact with the skin. Inhalants such as grain dust may affect farmers. The degree of eczema depends on the length of exposure and sensitivity to the substance. Symptoms may show within some weeks but it can often take months, years and sometimes decades before an eczema develops. Any part of the skin may become affected. but the most frequent sites are the hands, arms and the face, because these tend to be the least protected parts of the body. Occupational allergy may also present with pulmonary or upper sometimes decades before an eczema develops. Any part of the skin may become affected. but the most frequent sites are the hands, arms and the face, because these tend to be the least protected parts of the body. Occupational allergy may also present with pulmonary or upper respiratory treatments. Workers often get better over the weekend, on business trips, or vacation and symptoms recur after returning to the same work environment.respiratory treatments. Workers often get better over the weekend, on business trips, or vacation and symptoms recur after returning to the same work environment.

Role of Allergy in Various DiseasesRole of Allergy in Various Diseases

Who Becomes Allergic?Who Becomes Allergic?

PATHOGENISISPATHOGENISIS Anyone can develop an allergy, but the probability is increased if one or both parents suffer form some kind of allergic condition. Indeed, the presence of another allergic individual in the family is the strongest factor for predicting allergy in a child may not be. Conversely, allergic children are born to normal parents Anyone can develop an allergy, but the probability is increased if one or both parents suffer form some kind of allergic condition. Indeed, the presence of another allergic individual in the family is the strongest factor for predicting allergy in a child may not be. Conversely, allergic children are born to normal parents

and in such cases other factors, such as infection, may be responsible for the development of the allergy. Repeated exposure to a substance is required before the body can recognize it as foreign and mount an allergic response.and in such cases other factors, such as infection, may be responsible for the development of the allergy. Repeated exposure to a substance is required before the body can recognize it as foreign and mount an allergic response.

Allergic MechanismsAllergic Mechanisms The steps in lgE mediated allergy are:The steps in lgE mediated allergy are: SensitizationSensitization Initial exposure to allergen leads to production of allergen specific lge. antigen presenting cells (dentritic cells) recognize and process the antigen and presents it to tlymphocytes stimulating of cytgokines. direct interaction of t and b cells stimulates antigen specific lge production by b cells which binds with fc Initial exposure to allergen leads to production of allergen specific lge. antigen presenting cells (dentritic cells) recognize and process the antigen and presents it to tlymphocytes stimulating of cytgokines. direct interaction of t and b cells stimulates antigen specific lge production by b cells which binds with fc

receptor on mast cells and or basophills.receptor on mast cells and or basophills. Early phase Reaction (Immediate Hypersensitivity)Early phase Reaction (Immediate Hypersensitivity) it occurs within minutes of subsequent exposure of the lge antibody to the allergen. the allergen crosslinks the surface bound lge and stimulates the release of histamine upon reexposure of the same allergen mast cells (and basophills) degranuate releasing histamines tryptase and heparin along with newly synthesized it occurs within minutes of subsequent exposure of the lge antibody to the allergen. the allergen crosslinks the surface bound lge and stimulates the release of histamine upon reexposure of the same allergen mast cells (and basophills) degranuate releasing histamines tryptase and heparin along with newly synthesized

mediators like leukotrience and cytokines.mediators like leukotrience and cytokines. Late phase ReactionLate phase Reaction Allergen also stimulate immune cells (mast cells,Tcells) to produce inflammatory mediators (leukotriness,cytokines).These mediators act as post – capillary endothelial cell, promoting : Allergen also stimulate immune cells (mast cells,Tcells) to produce inflammatory mediators (leukotriness,cytokines).These mediators act as post – capillary endothelial cell, promoting : .. outflow of plasma leading to localized edema.outflow of plasma leading to localized edema. .. Adhesion of circulating leukocytes.Adhesion of circulating leukocytes. .. Infilltration of tisues by eosinophils,neutrophills and basophills.Infilltration of tisues by eosinophils,neutrophills and basophills. over the course of several hours, the infiltrating inflammatory cells become activated and release mediators stimulating and enhancing further inflammatory response.over the course of several hours, the infiltrating inflammatory cells become activated and release mediators stimulating and enhancing further inflammatory response. Type 1 IgE ReceptorsType 2 lgE ReceptorsTaget CellsMast Cells, BasophilsLymphocptes, Platelets, Eosinophils, Monocytes & MacrophagesAntibody Affinity for IgEHigh Affiinity for IgELow Affinity for IgEMediatorsHistamine, ECF-A, Leukotrienes, Bradykinins, Prostaglandins, PAF, Type 1 IgE ReceptorsType 2 lgE ReceptorsTaget CellsMast Cells, BasophilsLymphocptes, Platelets, Eosinophils, Monocytes & MacrophagesAntibody Affinity for IgEHigh Affiinity for IgELow Affinity for IgEMediatorsHistamine, ECF-A, Leukotrienes, Bradykinins, Prostaglandins, PAF,

anaphylatoxinsChemotactic Factors, IgE Binding Factors, Mitogens, inflammatory MediatorsanaphylatoxinsChemotactic Factors, IgE Binding Factors, Mitogens, inflammatory Mediators IgE is a homocytotrophic antibody – an antibody capable of interacting with target cells such that these cells release mediators on contact with specific antigen. There are two categories of lgE receptors depending upon the type of cells targeted, antibody affinity and the type of mediators released. IgE is a homocytotrophic antibody – an antibody capable of interacting with target cells such that these cells release mediators on contact with specific antigen. There are two categories of lgE receptors depending upon the type of cells targeted, antibody affinity and the type of mediators released. Why lgE and Not lgG?Why lgE and Not lgG? Acute allergic reactions result from the release of preformed granule associated mediators, deprived lipids, cytokines and chemokines when an allergen interacts with lgE that is bound to mast cells or basophils ny the chain of high affinity lgE receptor. This receptor also occurs on antigen presenting cells, where it Acute allergic reactions result from the release of preformed granule associated mediators, deprived lipids, cytokines and chemokines when an allergen interacts with lgE that is bound to mast cells or basophils ny the chain of high affinity lgE receptor. This receptor also occurs on antigen presenting cells, where it

can facilitate the lgE dependent trapping and presentation ofr allergens to T cells, Eosinophils also process high affintity lgE receptor, but in these cells it is almost entirely intracellular; after being released by degranulation of the eosinophil, it may help regulate local levels of lgE.can facilitate the lgE dependent trapping and presentation ofr allergens to T cells, Eosinophils also process high affintity lgE receptor, but in these cells it is almost entirely intracellular; after being released by degranulation of the eosinophil, it may help regulate local levels of lgE. The most important inducers of the production of lgE are inerleukin-4 and interleukin-13 these cytokines initiate transcription of the gene for the epsilon class of the constant region of the immunoglobulin (lg) heavy chain. The production of lgE also requires two transcription factors, nuclear factor-B and stat-6 the The most important inducers of the production of lgE are inerleukin-4 and interleukin-13 these cytokines initiate transcription of the gene for the epsilon class of the constant region of the immunoglobulin (lg) heavy chain. The production of lgE also requires two transcription factors, nuclear factor-B and stat-6 the

former pathway involves the co-stimulatory molecules CD40 and the CD4 ligand(CD154) and the latter is activated when interleukin-4 binds to the high affinity alpha chain of the interleukin-4 receptor.former pathway involves the co-stimulatory molecules CD40 and the CD4 ligand(CD154) and the latter is activated when interleukin-4 binds to the high affinity alpha chain of the interleukin-4 receptor. DiagnosisDiagnosis Who Should be tested for allergy ?Who Should be tested for allergy ? Generally, all individuals with severe, persisting or recurrent possible allergic symptoms and individuals with need for continuous prophylactic treatment should be tested for specific allergy irrespective of the age. The extent of allergy tests will typically depend on the age. The extent of allergy tests will typically Generally, all individuals with severe, persisting or recurrent possible allergic symptoms and individuals with need for continuous prophylactic treatment should be tested for specific allergy irrespective of the age. The extent of allergy tests will typically depend on the age. The extent of allergy tests will typically

depend on the age, positive family history, and the character of the symptomatology including possible seasonal or diurnal variations. When children are tested according to age for specific allergy diagnosis, additional testing might be considered for assessment of sensitization reflecting the atopic constitution. The depend on the age, positive family history, and the character of the symptomatology including possible seasonal or diurnal variations. When children are tested according to age for specific allergy diagnosis, additional testing might be considered for assessment of sensitization reflecting the atopic constitution. The accurate identification of the cause(s) of allergic symptoms is a cornerstone of management.accurate identification of the cause(s) of allergic symptoms is a cornerstone of management.

Evaluation of the patient”s environmentEvaluation of the patient”s environment Evaluation of the patient”s immunological responses to allergens.Evaluation of the patient”s immunological responses to allergens. It is essential for successful treatment that the allergens responsible for the symptoms are accurately identified. There are different ways to arrive at a diagnosis. The case history is extremely important in all allergy investigations. Based on what the patient tells about his/her symptoms, the doctor decides what tests, if It is essential for successful treatment that the allergens responsible for the symptoms are accurately identified. There are different ways to arrive at a diagnosis. The case history is extremely important in all allergy investigations. Based on what the patient tells about his/her symptoms, the doctor decides what tests, if

any, should be carried out.any, should be carried out. Case HistoryCase History The case history should form the basis for all allergy investigations in order to give the doctor an idea of the mechanisms and allergens causing the trouble, the doctor will question the patient or ask him/her to fill in a questionnaire. It is important to know when and how the symptoms developed. Also important if The case history should form the basis for all allergy investigations in order to give the doctor an idea of the mechanisms and allergens causing the trouble, the doctor will question the patient or ask him/her to fill in a questionnaire. It is important to know when and how the symptoms developed. Also important if

the relationship to seasons, damp weather, physical activity, certain foods, etc. Knowledge of personal habits such as smoking, occupation, hobbies etc, will be necessary and some information about the home can be important( e.g. whether there are pets, or fitted carpets in the house or if cleaning aggravates the relationship to seasons, damp weather, physical activity, certain foods, etc. Knowledge of personal habits such as smoking, occupation, hobbies etc, will be necessary and some information about the home can be important( e.g. whether there are pets, or fitted carpets in the house or if cleaning aggravates symptoms) A favorite cologne or perfume can be the cause of allergic conjunctivitis, while a soap may be the cause of chronic eczema. Finger polish may cause eczema. In nasal , the case history alone may give enough information to settle the diagnosis and the doctor can then decide which measures to take to help symptoms) A favorite cologne or perfume can be the cause of allergic conjunctivitis, while a soap may be the cause of chronic eczema. Finger polish may cause eczema. In nasal , the case history alone may give enough information to settle the diagnosis and the doctor can then decide which measures to take to help the patient. In more complicated cases, however, further investigations may be performed to get a final diagnosis.the patient. In more complicated cases, however, further investigations may be performed to get a final diagnosis.

Skin TestsSkin Tests There are several methods of skin testing. The most significant skin tests are those which correlate with the patient’s history(i.e, a positive shin test for ragweed is not significant if ragweed never causes allergy symptoms) drops of the suspected a;;ergens are put on the skin of the forearm and the skin is either pricked There are several methods of skin testing. The most significant skin tests are those which correlate with the patient’s history(i.e, a positive shin test for ragweed is not significant if ragweed never causes allergy symptoms) drops of the suspected a;;ergens are put on the skin of the forearm and the skin is either pricked

or scratched (prick or scratch test) through the drops. Suspected allergens can also be injected into the skin of the back ( intradermal skin test) After 15-20 minutes, if there is an allergy to one or more of the substances, a round wheal with a flare forms on the spots where the substances were injected . This may or scratched (prick or scratch test) through the drops. Suspected allergens can also be injected into the skin of the back ( intradermal skin test) After 15-20 minutes, if there is an allergy to one or more of the substances, a round wheal with a flare forms on the spots where the substances were injected . This may identify and confirm the allergy . However, desides causing the patient some trouble , the intradermal skin tests may not be very reliable . Drug treatment for the allergic symptoms in the 72 hours prior to the skin test may invalidate the results, and skin testing in small children is both inconvenient and unreliable.identify and confirm the allergy . However, desides causing the patient some trouble , the intradermal skin tests may not be very reliable . Drug treatment for the allergic symptoms in the 72 hours prior to the skin test may invalidate the results, and skin testing in small children is both inconvenient and unreliable.

Patch TestsPatch Tests Patch testing is used in the investigation of allergic contact dermatitis. The test in performed by using a small piece of blotting paper, moistened with the suspected substance, or a prepared strip containing various standard allergens. The raper of strip is taped to an area of healthy skin for 24 or 48 hours. If the patient Patch testing is used in the investigation of allergic contact dermatitis. The test in performed by using a small piece of blotting paper, moistened with the suspected substance, or a prepared strip containing various standard allergens. The raper of strip is taped to an area of healthy skin for 24 or 48 hours. If the patient

is allergic to the substance tested, eczems eill be seen where the test substance has been in contact with the skin.is allergic to the substance tested, eczems eill be seen where the test substance has been in contact with the skin. Provocation and Elimination TestsProvocation and Elimination Tests These tests are performed in the eyes and nose inh hay fever sufferers. A highly diluted allergen extract is dropped into the nose or eyes or is inhaled . The continued in this way using more concentrated allergens until the allergic symptoms are provoked. This shows that the tested allergen is responsible for the These tests are performed in the eyes and nose inh hay fever sufferers. A highly diluted allergen extract is dropped into the nose or eyes or is inhaled . The continued in this way using more concentrated allergens until the allergic symptoms are provoked. This shows that the tested allergen is responsible for the

patients symptoms. When allergy tl food is suspected, different foods ( usually those most commonly associated with allergy) are eliminated to see if the symptoms disappear. They are re introduced into the diet, one by one, to see if any of them causes a return to the symptoms. The most common food sensitivities patients symptoms. When allergy tl food is suspected, different foods ( usually those most commonly associated with allergy) are eliminated to see if the symptoms disappear. They are re introduced into the diet, one by one, to see if any of them causes a return to the symptoms. The most common food sensitivities are to cow”s milk, corn, wheat, eggs and soy. The skin and provocation tests, apart from being inconvenient to the patient, have other disadvantages.are to cow”s milk, corn, wheat, eggs and soy. The skin and provocation tests, apart from being inconvenient to the patient, have other disadvantages.

In-Vitro allergy Testing In-Vitro allergy Testing Because of the limitations and disadvantages associated with skin and provocation tests, there has been a need for more convenient and reliable methods. Today, there are laboratory tests available that accurately measure lgE, and a small blood sample is sufficient for allergy testing. These tests measure either the total Because of the limitations and disadvantages associated with skin and provocation tests, there has been a need for more convenient and reliable methods. Today, there are laboratory tests available that accurately measure lgE, and a small blood sample is sufficient for allergy testing. These tests measure either the total

amount of lgE in the blood, which indicates if your symptoms are of allergic origin or specific lgE, which tells the doctor which are causing the trouble.amount of lgE in the blood, which indicates if your symptoms are of allergic origin or specific lgE, which tells the doctor which are causing the trouble.

DIAGNOSTIC APPROACHDIAGNOSTIC APPROACH Total lgE TestTotal lgE Test This measures the total amount of lgE in the patient’s blood. This is compared to normal levels for the age and race. The level gives an indication of the patient’s degree of sensitisation to all allergens. Araised level This measures the total amount of lgE in the patient’s blood. This is compared to normal levels for the age and race. The level gives an indication of the patient’s degree of sensitisation to all allergens. Araised level

shows that the patient is probably allergic.shows that the patient is probably allergic. Allergen Specific lgE TestsAllergen Specific lgE Tests Often the doctor will be certain that the patient is suffering from an allergy and suspects a particular individual allergen. If this is the case, further testing with one or more specific lgE tests can confirm or identify Often the doctor will be certain that the patient is suffering from an allergy and suspects a particular individual allergen. If this is the case, further testing with one or more specific lgE tests can confirm or identify

the allergen(s) involved.the allergen(s) involved. Diagnostic lssuesDiagnostic lssues To interpret the results of allergen specific lgE testing, the following factors must be taken into consideration:To interpret the results of allergen specific lgE testing, the following factors must be taken into consideration: Allergen standardizationAllergen standardization Besides allergen characterization, allergen standardization is increasingly important. This is bcoming more significant particularly because of the need for quality assurance which is an integral part of the diagnosis Besides allergen characterization, allergen standardization is increasingly important. This is bcoming more significant particularly because of the need for quality assurance which is an integral part of the diagnosis

and treatment of allergy. It is critical that for every allergen the highest purity should be used in diagnostic tests. In order to ensure comparability between different lots, allergen quantification methods must adhere and treatment of allergy. It is critical that for every allergen the highest purity should be used in diagnostic tests. In order to ensure comparability between different lots, allergen quantification methods must adhere to international allergen standards. The clinical specificity of the tests is directly depending on the origin of the allergen extract in use. Their purity and their quantification.to international allergen standards. The clinical specificity of the tests is directly depending on the origin of the allergen extract in use. Their purity and their quantification.

Calibrator TraceabilityCalibrator Traceability The calibrator should be traceable to WHO standard reference preparation must be used in the assays for quantification of specific lgE antibodiesThe calibrator should be traceable to WHO standard reference preparation must be used in the assays for quantification of specific lgE antibodies Analytical sensitivityAnalytical sensitivity The analytical sensitivity of the lgE antibody test is determined in part by the labeled anti lgE antibody used in the second stage of the assay. Commercial labeled, affinity purified anti lgE antibodies function well The analytical sensitivity of the lgE antibody test is determined in part by the labeled anti lgE antibody used in the second stage of the assay. Commercial labeled, affinity purified anti lgE antibodies function well

as detection proteins ad enable the measurement of nanogram quantities of specific lgE antibodies.as detection proteins ad enable the measurement of nanogram quantities of specific lgE antibodies. Cross ReactivityCross Reactivity AnimalFoodBeefAll Milk products, VealPoultry(Chicken)Chicken egg, Chicken meat, Pheasant, Quail, PortridgeSalt water fishCod, Shellfish, perch, Herring, Sardine, Sole, Salaman, TunaFresh water AnimalFoodBeefAll Milk products, VealPoultry(Chicken)Chicken egg, Chicken meat, Pheasant, Quail, PortridgeSalt water fishCod, Shellfish, perch, Herring, Sardine, Sole, Salaman, TunaFresh water

fishTrout,Pike,Carp, EelShelfishOyster, Clams, Snail, OctopusCrustaceansCrabs, Prawns, Shrimps, Lobsters, ScallopsfishTrout,Pike,Carp, EelShelfishOyster, Clams, Snail, OctopusCrustaceansCrabs, Prawns, Shrimps, Lobsters, Scallops Allergic cross reactions exist between many foods sand other products. In beef allergy cross reactivity may be present with all other cow’s milk products and veal. In seafood allergies involving fresh and saltwater Allergic cross reactions exist between many foods sand other products. In beef allergy cross reactivity may be present with all other cow’s milk products and veal. In seafood allergies involving fresh and saltwater

fish, shelfish and crustaceans, many cross reactions exist.fish, shelfish and crustaceans, many cross reactions exist. Cross reactions Between Allergens of Animal Food OrginCross reactions Between Allergens of Animal Food Orgin Pollen FoddSpring PollenPitted Fruits (plums, cherries), Carrots, Potatoes, Kiwi, Mango, Curry, Anise, Peppermint.Grain Flour Grass Celery, Parsley, Curry, Thyme, SoyaBeans, PeanutsMugwartCelery, Pollen FoddSpring PollenPitted Fruits (plums, cherries), Carrots, Potatoes, Kiwi, Mango, Curry, Anise, Peppermint.Grain Flour Grass Celery, Parsley, Curry, Thyme, SoyaBeans, PeanutsMugwartCelery,

CarrotsHerbs Spices, Herbal Teas (Fennel, chamomile)CarrotsHerbs Spices, Herbal Teas (Fennel, chamomile) Clinical CorrelationClinical Correlation The detection of allergen specific IgE antibodies does not necessarily correlate with positive skin test reactions. Mast cell bound IgE has a considerable longer half life (month to years) than serum IgE (2-3 days). A The detection of allergen specific IgE antibodies does not necessarily correlate with positive skin test reactions. Mast cell bound IgE has a considerable longer half life (month to years) than serum IgE (2-3 days). A

positive skin test in patients with pollen allergy is still detectable after the end of pollen season whereas IgE antibody may decline rapidly.positive skin test in patients with pollen allergy is still detectable after the end of pollen season whereas IgE antibody may decline rapidly. The specific IgE antibody level may not correlate with the sverity of symptoms and the clinical presentation. Higher levels of allergen specific IgE antibodies are found in severe atopic dermatitis and in p[atients The specific IgE antibody level may not correlate with the sverity of symptoms and the clinical presentation. Higher levels of allergen specific IgE antibodies are found in severe atopic dermatitis and in p[atients

with severe allergic reactions not undergoing adequate treatment.with severe allergic reactions not undergoing adequate treatment. A decline in specific IgE antibody levels during therapu, including desensitization treatment does not necessarily occur. Also, a decline in specific IgE antibodies does not confirm the success of therapy.A decline in specific IgE antibody levels during therapu, including desensitization treatment does not necessarily occur. Also, a decline in specific IgE antibodies does not confirm the success of therapy. Biological FactorsBiological Factors A number of factors including lifestyle and living conditions have an impact on the IgE levels. Active and passive smoking may result in increased IgE.A number of factors including lifestyle and living conditions have an impact on the IgE levels. Active and passive smoking may result in increased IgE. In-Vitro IgE Testing AdvantagesIn-Vitro IgE Testing Advantages Laboratory tests for IgE plays an important role in allergic rhinitis, allergic asthma and in some forms of eczema. Detecting and accurately measuring the amount of IgE may be of great importance when Laboratory tests for IgE plays an important role in allergic rhinitis, allergic asthma and in some forms of eczema. Detecting and accurately measuring the amount of IgE may be of great importance when

diagnosing allergies.diagnosing allergies. Laboratory tests are accurate and convenient and can be used for a broader range of allergens than skin tests can. They are also more suitable for babies and patients with eczema in whom it is difficult to do skin Laboratory tests are accurate and convenient and can be used for a broader range of allergens than skin tests can. They are also more suitable for babies and patients with eczema in whom it is difficult to do skin

tests. Laboratory tests are not affected by symptoms or by treatment. As a results of dramatic developments in diagnostic medical technology in recent years, coupled with the increasing knowledge and tests. Laboratory tests are not affected by symptoms or by treatment. As a results of dramatic developments in diagnostic medical technology in recent years, coupled with the increasing knowledge and understanding of allergic processes by medical researchers and doctors, it is possible to identify the cause of an allergy in over 95% of cases if skin tests and laboratory tests are used. The doctor can choose which understanding of allergic processes by medical researchers and doctors, it is possible to identify the cause of an allergy in over 95% of cases if skin tests and laboratory tests are used. The doctor can choose which tests will suit the individual patient and the individual circumstances. It is important that the results of the tests are carefully interpreted by a doctor who has training in and therefore a good understanding of tests will suit the individual patient and the individual circumstances. It is important that the results of the tests are carefully interpreted by a doctor who has training in and therefore a good understanding of allergy. Only then can the best treatment and patient management be carried out. Better diagnosis can then be coupled with the recent developments in chemotherapeutics, with new classes and new formulations of allergy. Only then can the best treatment and patient management be carried out. Better diagnosis can then be coupled with the recent developments in chemotherapeutics, with new classes and new formulations of drugs, leading to greatly improved management of the allergic patient.drugs, leading to greatly improved management of the allergic patient.

When To Ask For IgE TestsWhen To Ask For IgE Tests Serum IgE tests can be generally recommended in :Serum IgE tests can be generally recommended in : Diagnosing AtopyDiagnosing Atopy

DIAGNOSISDIAGNOSIS Diagnosis of IgE myelomaDiagnosis of IgE myeloma Diagnosing AllergiesDiagnosing Allergies Extended investigation of allergies parallel to screening for specific IgE antibodies as part of differential evaluation of diseases with a possible allergic component.Extended investigation of allergies parallel to screening for specific IgE antibodies as part of differential evaluation of diseases with a possible allergic component. Extended investigation of allergies in case of eosinophilic pulmonary infiltrations, allergic aspergilosis, allergic alveolitis.Extended investigation of allergies in case of eosinophilic pulmonary infiltrations, allergic aspergilosis, allergic alveolitis. Lllness associated with eosinophilia or fever of unknown origin (drung related fever)Lllness associated with eosinophilia or fever of unknown origin (drung related fever) Suspected presence of parasitic diseases in case of blood eosinophilia of unknown origin with unsuccessful parasite detection.Suspected presence of parasitic diseases in case of blood eosinophilia of unknown origin with unsuccessful parasite detection. Congenital Immunodeficiency syndromesCongenital Immunodeficiency syndromes Acquired immunodeficiency syndromes.Acquired immunodeficiency syndromes. Graft versus host diseasesGraft versus host diseases Severe burnsSevere burns To rule out broncho pulmonary aspergillosisTo rule out broncho pulmonary aspergillosis Clinical DisorderSerum lgE levelsAtopic DiseasesExpgempis asthma in 60% patientsHay fever in 30% PatientsIncreasedAtopic EczemaIncreasedAtopic Clinical DisorderSerum lgE levelsAtopic DiseasesExpgempis asthma in 60% patientsHay fever in 30% PatientsIncreasedAtopic EczemaIncreasedAtopic

dermatitisIncreasedParasitic diseases(ascariasis, visceral larva mirgans, hookworm disease, schistosomiasis, ankylostomasis, echinococcus infections)IncreasedigE dermatitisIncreasedParasitic diseases(ascariasis, visceral larva mirgans, hookworm disease, schistosomiasis, ankylostomasis, echinococcus infections)IncreasedigE myelomaIncreasedHyper igE syndromeIncreasedCellular immundeficienciesWiskott Aldrich syndromePartial Digeorge,s syndromeNezelof syndrome(thymic myelomaIncreasedHyper igE syndromeIncreasedCellular immundeficienciesWiskott Aldrich syndromePartial Digeorge,s syndromeNezelof syndrome(thymic alymphoplasia)IncreasedHereditary deficienciesDecreasedAcquired immunodeficiency(SCID)DecreasedAtaxia – TelangiectasiaDecreasedNon lgE alymphoplasia)IncreasedHereditary deficienciesDecreasedAcquired immunodeficiency(SCID)DecreasedAtaxia – TelangiectasiaDecreasedNon lgE myelomaDecreasedAsthmaNormal/LowmyelomaDecreasedAsthmaNormal/Low

ReferencesReferences NHLRI, 2/97 Guidelines for DX, Treatment of AsthmaNHLRI, 2/97 Guidelines for DX, Treatment of Asthma Cecil’s Textbook of Medicine, 21st Edition, (2000)Cecil’s Textbook of Medicine, 21st Edition, (2000) Clinician’s Guide to Holistic Medicine, R. Anderson, M D (2001)Clinician’s Guide to Holistic Medicine, R. Anderson, M D (2001) Unproven techniques in allergy diagnosis: B Wothrich, University of Zurich, Zurich. SwitzeriandUnproven techniques in allergy diagnosis: B Wothrich, University of Zurich, Zurich. Switzeriand Keeping allergy on the agenda: integrated guidelines for respiratory disease in developing countries: R.G English, L.R fairall, E.d Bateman The University of cape Keeping allergy on the agenda: integrated guidelines for respiratory disease in developing countries: R.G English, L.R fairall, E.d Bateman The University of cape

Town Lung institute,Town Lung institute, Mowbray, Cape Town, South Africa Mowbray, Cape Town, South Africa Allergy Testing : James T. Li, M.D, PH.D Mayo Clinic and Foundation. Rochester, MinnesotaAllergy Testing : James T. Li, M.D, PH.D Mayo Clinic and Foundation. Rochester, Minnesota Correlation between eosinophil count, total serum igE and skin prick test for allergy diagnosisCorrelation between eosinophil count, total serum igE and skin prick test for allergy diagnosis E Viaski, University childrens Hospital, Department of Pulmoallergology, Skopje, MacedoniaE Viaski, University childrens Hospital, Department of Pulmoallergology, Skopje, Macedonia The Royal College of Physicians Committee on Clinical immlunoogy and lallergy: Clinical Exp Allergy 1962,22: Suppl. 3.The Royal College of Physicians Committee on Clinical immlunoogy and lallergy: Clinical Exp Allergy 1962,22: Suppl. 3. In vitro diagnostic methods in the evaluation of food allergy, 2nd edition, Blackwell, Cambridge, USA 1997,p.137In vitro diagnostic methods in the evaluation of food allergy, 2nd edition, Blackwell, Cambridge, USA 1997,p.137

To Whomsoever It May ConcernTo Whomsoever It May Concern This is confirm that Mr. RAEES AHMED Passport No. E5949054 was employed with us since July 2005 To March 2008 in the Capacity of Chargent and we found hun satisfactory in his works.This is confirm that Mr. RAEES AHMED Passport No. E5949054 was employed with us since July 2005 To March 2008 in the Capacity of Chargent and we found hun satisfactory in his works. We wish him “All the Best in his future tenures”We wish him “All the Best in his future tenures” For al jawadri General Maintenance For al jawadri General Maintenance Authorized Signatory Authorized Signatory