Twenty-one year old woman with severe eosinophilia and left bundle branch block.

Peripheral and tissue eosinophilia can occur in a wide variety of disease processes that include infectious, allergic, and primary hematologic disorders, and other more rare diseases such as hypereosinophilic syndromes (HES). We describe a case of a patient with severe eosinophilia and left bundle branch block. A 21-year-old woman with asthma and allergic rhinitis presented with neck pain and cough for >6 months with no other complaints. Physical exam was normal except for fever and minimal expiratory wheezes. Chest CT revealed diffuse airway inflammation with bronchiectasis. Admission electrocardiogram (EKG) was normal. Initial laboratory tests showed an absolute eosinophil count of 30,000 cells/mL. A thorough workup for eosinophilia was initiated, but the patient subsequently left against medical advice. The next day, in the outpatient pulmonary clinic, she was found to be tachycardic and an EKG showed sinus tachycardia with a new left bundle branch block. Laboratory tests revealed an eosinophil count of 33,200 cells/mL and elevated troponins. She was started on i.v. Solu-Medrol (Pfizer, Inc.). The next day, her EKG returned to normal. Three days later her absolute eosinophil count normalized. Identifying the cause of marked, persistent eosinophilia is a challenging problem. Excluding the more common causes of severe eosinophilia is required before making a diagnosis of HES and early therapeutic intervention can prevent morbidity from the disease.

Prevalence of migraine headaches in patients with allergic rhinitis.

BACKGROUND: Histamine has been implicated in the pathogenesis of migraine headaches. Because allergic rhinitis (AR) is a histamine-driven syndrome and the nasal passage is in close proximity to the central nervous system, we hypothesize that AR may trigger migraine headaches. OBJECTIVE: To determine the prevalence of migraine headaches in patients with and without AR. METHODS: Allergic rhinitis was diagnosed based on skin or radioallergosorbent test results, clinical history, and physical examination findings. The diagnosis of migraine headache was made if patients fulfilled the International Headache Society criteria. Surveys were obtained from hospital-based allergy, pediatric, and internal medicine clinics, all serving the same inner-city population. RESULTS: A total of 294 surveys were completed. Of 76 patients in the AR group, 26 (34%) had headaches meeting the International Headache Society criteria for migraines, and of the 57 patients in the non-AR group, only 2 (4%) had headaches that met the criteria. A Fisher exact test showed P = 8.2 x 10(-6). The odds ratio was 14.3, which signifies that the odds of having migraine headaches is 14.3 times higher in the AR group than in the non-AR group. CONCLUSIONS: There is a high prevalence of migraine headaches in patients with AR compared with those without AR. We propose that histamine plays a key role in triggering migraines by means of vasodilation and inflammation in the pathogenesis of migraine headaches.

Monoclonal gammopathy in association with allergic disorders of the skin and respiratory tract.

Monoclonal gammopathy is a condition characterized by the abnormal proliferation of a single clone of plasma cells, which produces a homogeneous monoclonal protein. It has been reported to occur in association with urticaria in the context of Schnitzler's syndrome and also has been observed to occur in angioedema with acquired C1 esterase inhibitor deficiency. We report 11 cases of monoclonal gammopathy presenting to practicing allergists (>2.5% of those screened) primarily in association with dermatologic disorders, i.e., urticaria, angioedema, and nonspecific dermatitis, but also with allergic respiratory disorders, i.e., allergic rhinitis, chronic sinusitis, and asthma. Most of the patients with dermatologic manifestations had respiratory disorders as well, three with chronic sinusitis. To our knowledge, these are the only such cases reported in patients with urticaria or angioedema in the absence of Schnitzler's syndrome or C1 inhibitor deficiency or in association with chronic sinusitis, allergic rhinitis, or asthma. Monoclonal gammopathy, angioedema, urticaria, allergic respiratory disorders, and sinusitis could be linked through antigenic stimulation as a trigger, either infectious, as in chronic sinusitis; self-antigens, as in autoimmunity; or the monoclonal gammopathy itself, causing idiotype-anti-idiotype immune complexes and inflammatory disease. The allergist, dermatologist, otolaryngologist, and primary care physician should all maintain a high index of suspicion for the occurrence of monoclonal gammopathy in the "allergic" population. Serum protein electrophoresis and/or serum immunofixation are useful screening tools. When monoclonal gammopathy is found, the presence of light chains in the urine should be assessed and the patient should be referred for prompt hematology-oncology evaluation with periodic monitoring for the development of plasma cell dyscrasias. Additional prospective study is necessary to determine the true prevalence of monoclonal gammopathy in the population presenting to the practicing allergist.

Allergic rhinitis in children with attention-deficit/hyperactivity disorder.

BACKGROUND: Both allergic rhinitis and attention-deficit/hyperactivity disorder (ADHD) are common pediatric conditions associated with learning difficulties and sleep disturbances. There are conflicting research data regarding the association between ADHD and atopic disorders. OBJECTIVE: To determine the prevalence of allergic rhinitis in patients with physician-diagnosed ADHD. METHODS: Patients 5 to 18 years of age who presented with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of ADHD to an outpatient pediatric psychiatry clinic were screened for allergic rhinitis with focused history, physical examination, and skin prick testing to common aeroallergens. RESULTS: Thirty patients were interviewed, with 23 of these undergoing physical examination and skin prick testing. Eighty percent reported allergic rhinitis symptoms, whereas 61% had at least 1 positive prick skin test result. Forty-three percent showed typical physical signs of allergic rhinitis, 100% had a positive atopic family history, and 53% had other associated atopic disorders. CONCLUSIONS: Most children with ADHD displayed symptoms and skin prick test results consistent with allergic rhinitis. Nasal obstruction and other symptoms of allergic rhinitis could explain some of the cognitive patterns observed in ADHD, which might result from sleep disturbance known to occur with allergic rhinitis. Therefore, evaluation and treatment of allergic rhinitis could benefit patients with ADHD.

Asthma severity, psychiatric morbidity, and quality of life: correlation with inhaled corticosteroid dose.

OBJECTIVES: Psychiatric phenomena in asthma has been debated for some time. Inhaled corticosteroids (ICS) are a significant part of treatment. We attempted to quantify the prevalence of psychiatric morbidity relative to asthma severity, quality of life (QOL), and ICS dose. DATA SOURCES: Fifty asthmatic patients (18 > or = X < or =75 years) on ICS, attending an urban clinic had asthma and ICS dose stratified by symptom severity and preparation potency. Peak flow and forced expiratory volume in 1 second (FEV1) were measured. Patients completed general QOL and disease-specific QOL questionnaires, along with psychiatric rating scales. RESULTS: Patients (n = 50) clustered in the 40-59 year range (n = 27, 54%) and were predominantly female (n = 44, 88%) Hispanics (n = 30, 60%), with mild-moderate asthma (n = 18, 36%) and on low-dose ICS (n = 22, 44%). FEV1 ranged from 32 to 123 (mean 76.98, SE 3.01). Peak flow ranged from 210 to 590 (mean 407.83, SE 13.24). Prevalence of anxiety and depressive symptoms were higher than expected (Kendall's tau-c, n = 50, P < .01). Independently, high ICS dose and asthma severity correlated directly with all measures of psychiatric morbidity (Pearson's r0.781, P < .01). High ICS dose correlated inversely with SF-36 Mental Component Scale (Pearson's r0.681, P < .01) and directly with FEV1 and peak flow when age/sex adjusted (Spearman's rho: 0.660, P < .001). CONCLUSIONS: Psychiatric morbidity is more prevalent in this population and impacts negatively on QOL. Use of high-dose ICS benefited pulmonary function and "physical" QOL, yet may have negatively affected patients' mental well-being. Longitudinal follow-up, extension of sample size, and better study control would allow closer approximation of possible negative associations with ICS.