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Suggest treatment for difficulty breathing due to seasonal allergies

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Posted on Tue, 7 Jun 2016
Question: I have had seasonal allergies since childhood, especially in spring and fall, and when around animals with fur (not with fish or birds). When symptomatic, I am totally prostrated, and antihistamines/decongestants are the order of the day. On rare occasions, I have been treated with steroids (injected and/or oral). In the last few years, my breathing during allergy season became so bad that I was placed on inhaled beta-agonists and inhaled steroids. PFTs were c/w RAD. In the past, I have had to undergo endoscopic sinus surgery to address MECHANICAL problems with drainage, and have had nasal-septal deviation repair as well as removal of nasal polyps and spurs. A few times I have been an inpatient for IV antibiotics for recurrent frontal sinusitis.

I've been seen by an allergist, and had the standard prick skin testing, and interestingly was positive only for allergies to dog/cat. I was not on steroids or antihistamines at the time of testing, and was begun on desensitization injections (I own a service-dog). In the last month, I have had return of sinus symptoms while on once-monthly desensitization injections. My ID doc gave me a 5-day course of Levaquin which did not help. I told my allergist about non-improvement on Levaquin, and he placed me on an extended course of amoxicillin and oral prednisone, with the latter tapered over a MONTH. CT scan of sinuses showed no fluid, just mild septal deviation and findings c/w mild pan-sinusitis.

I understand that this could be viral, but it has hung on for about 6 weeks now. Treatment with oral prednisone has been the most beneficial treatment employed to date. As an aside, all of my immunoglobulins are on the threshold of being low (IgA, IgG, and IgM). I am HIV+, but viral loads are not detectable and CD4s are in the 600s.
I have had IgE drawn, but remember it as being normal. Is the IgE level being normal when all other immunoglobulins are borderline low suggest that the IgE should also be low, and because it is not, support a finding of allergic etiology?

I've seen ENT, and he noted boggy sinuses with evidence of epistaxis, and TMs with diminished light reflex but no visible A/F levels. Maxillary sinus tenderness was noted.
In addition to being HIV+, I am concerned about possibly having a primary immunodeficiency. How low must the IgA be before having a low threshold for antibiotics in a case like this?

My eosinophils (both absolute and % of WBCs) are elevated perennially, but not high enough for the diagnosis of hypereosinophilia. An EGD w/biopsies done recently for odynophagia revealed increased tissue eosinophils, but again not high enough for the diagnosis of eosinophilic esophagitis. What do you recommend?
doctor
Answered by Dr. Neel Kudchadkar (6 hours later)
Brief Answer:
Kindly take a course of CBT. It's effective, and downloadable. (Yale.edu)

Detailed Answer:

Hi.

1. I would rule out primary immunodeficiency. This is impossible. If this were so, you would never have had the history of seasonal allergies since childhood, which are the product of immune system hyperactivity.

2. Eosinophilia is a common sign of infections, typically of nematodes, in even persons who do not have HIV. This certainly does not warrant a diagnosis of eosinophilic esophagitis. Furthermore, despite the EGD, you must admit that the biopsies have acquitted you of esophagitis. Also, note that odynophagia is not neccessarily due to esophageal issues and can be due to trauma (even toothbrush trauma) to the pharynx. Rest assured, your esophagus is clear.

3. You mention that you remember IgE to be normal. You remember the others to be slighty borderline. You mention that this fact should indicate that the normal IgE should be subnormal. This is not logical. In logic, this is called as a fallacy. The line of your query in which you mention these statements are called as a tautology in logic.

Note this:

If IgE IS NORMAL AND IgA AND IgM ARE < NORMAL THEN IgE is AS NORMAL AS IT IS NORMAL. (Logical Truism)

Note that:

A. You know you have a history of allergy since childhood.
B. Therefore there is an allergic etiology.
C. You seek to confirm this with Ig levels.
D. You are attempting to create a hypothesis of which there is already a proof.
E. The Ig levels now act as a confounder in the hypothesis.
F. You have succeeded in creating a Paradoxical conundrum.

(please read up on logic and reasoning in wikipedia mathematics portal, or please read up on medical statistical decision making process)

Final thoughts and diagnosis.

1. That there is a definite thought disorder. (more than 2 fallacies in 1 paragraph)
2. That there is a definite concreteness to your thought process.
3. That the cognitive effects of chronic HIV infection are known.
4. That you do not need any medication, however, I would definitely ask you to take a weeks course on cognitive and dialectical therapy.

Most important facts to be remembered are that once someone is HIV+, regardless of Ig Levels, a fixed high dose antibiotic is administered. Note this, that it is the standard operating procedure internationally. Note that the BMI, weight and other concurrent drugs in regimen and antibiotic sensitivities are kept in mind too, while administering these antibiotics, yet the dose is higher than that of an HIV negative person, and the baseline is now standardized for causcasian patients. This is a pharmacological fact.

I am open to your thoughts on this, if you don't like this answer, which is the truth, then we can discuss alternative treatments. There are many.

Do write back if you're not happy, or have doubts as regards my diagnosis.

Dr. Neel Kudchadkar
Above answer was peer-reviewed by : Dr. Raju A.T
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Answered by
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Dr. Neel Kudchadkar

General & Family Physician

Practicing since :2004

Answered : 532 Questions

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Suggest treatment for difficulty breathing due to seasonal allergies

Brief Answer: Kindly take a course of CBT. It's effective, and downloadable. (Yale.edu) Detailed Answer: Hi. 1. I would rule out primary immunodeficiency. This is impossible. If this were so, you would never have had the history of seasonal allergies since childhood, which are the product of immune system hyperactivity. 2. Eosinophilia is a common sign of infections, typically of nematodes, in even persons who do not have HIV. This certainly does not warrant a diagnosis of eosinophilic esophagitis. Furthermore, despite the EGD, you must admit that the biopsies have acquitted you of esophagitis. Also, note that odynophagia is not neccessarily due to esophageal issues and can be due to trauma (even toothbrush trauma) to the pharynx. Rest assured, your esophagus is clear. 3. You mention that you remember IgE to be normal. You remember the others to be slighty borderline. You mention that this fact should indicate that the normal IgE should be subnormal. This is not logical. In logic, this is called as a fallacy. The line of your query in which you mention these statements are called as a tautology in logic. Note this: If IgE IS NORMAL AND IgA AND IgM ARE < NORMAL THEN IgE is AS NORMAL AS IT IS NORMAL. (Logical Truism) Note that: A. You know you have a history of allergy since childhood. B. Therefore there is an allergic etiology. C. You seek to confirm this with Ig levels. D. You are attempting to create a hypothesis of which there is already a proof. E. The Ig levels now act as a confounder in the hypothesis. F. You have succeeded in creating a Paradoxical conundrum. (please read up on logic and reasoning in wikipedia mathematics portal, or please read up on medical statistical decision making process) Final thoughts and diagnosis. 1. That there is a definite thought disorder. (more than 2 fallacies in 1 paragraph) 2. That there is a definite concreteness to your thought process. 3. That the cognitive effects of chronic HIV infection are known. 4. That you do not need any medication, however, I would definitely ask you to take a weeks course on cognitive and dialectical therapy. Most important facts to be remembered are that once someone is HIV+, regardless of Ig Levels, a fixed high dose antibiotic is administered. Note this, that it is the standard operating procedure internationally. Note that the BMI, weight and other concurrent drugs in regimen and antibiotic sensitivities are kept in mind too, while administering these antibiotics, yet the dose is higher than that of an HIV negative person, and the baseline is now standardized for causcasian patients. This is a pharmacological fact. I am open to your thoughts on this, if you don't like this answer, which is the truth, then we can discuss alternative treatments. There are many. Do write back if you're not happy, or have doubts as regards my diagnosis. Dr. Neel Kudchadkar