Gentowa

House bee (Apis mellifera)

● the incidence and bites are common due to their spread extent considering the honey production and the plants fertilisation

● lives in bee hives, nests and tree hollows

● is generally not aggressive; it does not sting if it is not provoked

● always looses its sting

● appears more often at the beginning of the summer

African bee – cross breaded

● came to Brazil in 1956 for the sake of breeding improvements, but it gained aggressive features; it gradually spreads through the whole continent northwards

● is dangerous due to its extreme aggression, it attacks in hundreds

Bumblebee (Bombus terrestris)

● robust hairy insect with distinctive colours

● nests in the ground made out of wax and collected fibrous material

● nests look like grapes

● is usually not aggressive, it does not sing until being provoked

Wasp (Vespula vulgaris)

● almost without hairs with typical black and yellow stripes on the abdomen

● nests on the ground, or under wood

● makes the nests from chewed wood with more small holes layers situated one under another

● is attracted to food and sweet beverages – often flies around in garden restaurants and when people eat outside

● is very aggressive and attacks even without being provoked

● loose the sting only seldom

● usually appear in the late summer and autumn (vintage time)

The very important fact relates to the information about the previous bites and their clinical consequences (local reaction – global reaction, its therapy duration, way and effect). If it is possible, the identification of the insect (e.g. wasp, bee) will be suitable, as well. You can be allergic to one or more insect species.

The allergy reaction initiator determination is important for the therapy, but also for the prevention and avoidance of further episodes.

If you do not know the name of the insect, the identification can be helped by following facts:

● how did it look like? the colour, pattern

● where was it found? (trees, grass, ground)

● how did it behave? (was it provoked into biting; was it aggressive)

● did it leave the sting in the affected spot?

The professional diagnosis is made with the help of the skin tests with the toxin of the particular suspicious insect (commercially prepared). According to the severe reactions danger many various concentrations are gradually used.

If the skin tests are not persuasive, the laboratory examination, where all IgE type antibodies against the insect species toxins (as far as we are concerned it goes for bees and wasps) are determined, will be made.

The skin tests are necessary supplements of all basic allergist examinations. The allergic hypersensitiveness proof was discovered by Charlie Blackley already in 1865. The technique

was later on improved by Grant Lewis, Pepyes and others, who introduced the prick test (stinger) usage. Nowadays the standardized method introduced by the European allergist and clinical immunology academy.

The skin test in based on the fact, that sensitive allergic patient has specific antibodies against the allergens not only in the particular organ, in which the clinical symptoms are active, but also in the cell membrane – mastocyte which are in the skin. While testing, the suspect allergen is injected into the patients´ skin near the forearm. The allergen choice is made according to the patients´ data on the clinical symptoms period. The standard group of allergens, which includes the following, is used:

● trees pollen

● grass pollen

● rye

● worm wood

● ambrosia

● mould

● feather

● mites

● positive control (histamine)

● negative control (usually a solution with dissolved allergens)

According to the seasonality, others allergens are added. If the patient is in the contact with the animals, the animal allergens (dog, cat, etc) are tested, as well. Before the testing the patient should cease the anti allergic treatment (the antihistamines for at least one week), but others, as well. For example many preparations used by the psychiatrists relieve even the skin reaction at the skin tests.

When possible, the patient should be tested even off pollen season. It is not appropriate to test somebody during or right after the infection since it can cover the reaction, as well. For checking the skin test realisation correctness beside the allergens, the positive and the negative control is injected. As the positive control histamine is used – a chemical, which is released during the allergic reaction in general, i.e. test with this chemical can be positive even in the case of the health people. If this reaction after the testing is negative, the test is not valid, since some of the processes or the medications relieved all reactions.

The negative checking is, on the contrary, is injected in order to exclude the reaction, which is only mechanical – the injury or the injection itself, or the allergic reaction to the solution, eventually to the conservative chemical in the allergen solution. The skin tests allergens are made commercially. Their content and dilution are standardised.

How the allergy is diagnosed by the doctor

The diagnosis procedure is not easy. The clinical symptoms of the different origin illness are often similar. For instance the symptoms of the allergic fever – red stuffy nose, sneezing, nose secretion are the same as while having the cold (it is usually caused by a simple viral inflammation). But the treatment approach is different. Therefore the diagnosis procedure requires besides the judgement of the current health conditions further information, too.

The basis of all allergic examination is the detailed anamnesis. It is actually the list of all factors, which relate (sometimes only seemingly for the patients) to the illnesses.

The family anamnesis is an information on the illnesses appeared in the patient family. Naturally, the blood relations, not he wife or the brother-in-law, are important. The allergic reaction, their ancestors – father, grandmother, siblings or children-suffered from, indicates the relation to the current illness of the patient. The allergy predisposition is inherited. While the child of the parents, who do not suffer any allergy, inclines to the allergy at the odds of approximately 20%, the odds of the allergy increases up to 50% concerning the child of at least one allergic parent. If the mother suffers any allergy, the odds will increase even more and in the case of both allergic parents, it is almost 100% certain, that their child will suffer the allergy (especially if both parents are allergic to the same allergens).

Personal anamnesis includes the facts, which precedes the particular current illness. In the anamnesis, all the previous illnesses, we have undergone, are listened. The eczemas in the childhood, serious allergic reaction suffered years ago, or the repeated infections – all these are information, which indicate the possible immune system disorder or direct the allergic “before-period”. Concerning the women the important information is the number of the deliveries and

the development of the pregnancy, concerning the children, the time until they were nursed,

when they started to eat the baby food, is of the greatest importance.

The working anamnesis is the information on the surroundings, where we spend the main part of our day. The important facts refer not only to conditions of the building (cleanness, humidity, thermo regime) but also all things we come into contact with – the production, administration, special operations and chemicals. The significant information are the protection regime against the potential harmful chemicals at the workplace and our approach to it. The information about how we spend our spare time – our hobbies, the sport, etc, places where we have the chance of the contact with the factors initiating or starting the allergy, should be a part of this analysis, too.

The current illness – its description is the most important part of the “testimony” and no basic information can be omitted in it.

● illness start and description

● your own symptoms descriptions

● seasonal presence of the clinical effects (per year, during the summer, etc)

● allergic (not allergic) initiating factor – if we know it or if it seems to be assumed

● lifestyle influence

* the symptoms occurrence frequency and the seriousness symptoms

* influence on the occupation ( study)

* extra working activities (sport, hobby)

* sleep

● environmental allergens – surroundings allergens – (at home, work)

● existing treatment – ( if already treated)

* effect (little, significant; stopped to be effective after a period of time)

* side-effects

* satisfaction and the willingness to undergo this type of treatment.

The information on the further potential illnesses we have, especially on medications we take, is important. Many can influence not only the diagnosis, but also the particular allergic reaction itself – and not only in the negative sense – worsen of the clinical condition or on the contrary- covering of the particular typical symptoms.

The physical examination is the basis in all cases. The doctor examines all systems. He or she examines the skin al over the body, where the symptoms – even not the most serious and hence hidden, which the patient himself does not have to notice – inflammation, reaction to any mechanic irritation, dryness or wetness of the skin, nails, hair, are looked for. The oral cavity reveals the potential inflammation- infectious, but allergic, as well.

The nasal mucosa swelling and congestion, nasal discharge, red skin around the nostrils caused by the mechanic irritation are the symptoms of the common cold. The patients with the nasal congestion breathe through the mouth, which are open all the time. The nasal congestion As far as the children are concerned, the nasal congestion is revealed by the line on the top, especially the so called allergic salute (greeting), it is started with. It is a “gesture” of pushing the top of the nose up with the palm, while the nasal cavity is being released.

The auscultatory examination – examination with the phonendoscope – enables to hear the breathing sound. Unlike the healthy lungs, the patients with the clinical asthma make crunching, bubbling or whistling sounds while breathing. They do not have to be loud so that only the experienced ear of the doctor can hear and identify them. The palpating and percussing of the rib cage and the abdomen provides further information.

The entire examination, especially the first visit to the specialised doctor is necessary. Therefore even while examining the patients, who are think that they have “only” a common cold, we should expect the complex examination.

How does the skin test reaction look like?

The applied allergens are bound on the antibodies molecules IgE - on the outside part of the mastocytes and through the transfer of the signal their degranulation and the allergic reaction mediators release occur. These initiate the reaction through the affect on the surrounding blood vessels, the symptoms of which are the flush, the itch and the swelling with the diameter of several millimetres in the place of the injection. On the reaction, which starts approximately after 5 minutes from the allergen application, takes part also the so called substance P, which is released from the sensitive nerve ending, after the histamine stimulation. The reaction culminates in the period of 15-20 minutes, when the doctor subtracts it, after this time the reaction decreases.

The skin test realisation is not painful for the patient. On the palm side of the forearm the drops of the examining allergens are applied. In every drop a gentle puncture with the plastic or metal tool with the small sharp top is made. The skin is punctured only on the top skin layer so that the place does not have to bleed at all. After 20 minutes the reaction is judged. Places, which are either red or swollen in the same way as after applying the histamine, indicate that the reaction is positive. The patient can react to one or ore allergens. Beside the reaction when the small papule with the diameter of several millimetres appear, which is the most common reaction, the more extensive local reaction – of several centimetres, in rare cases even the swelling of the hand come about. These reactions cease to occur spontaneously after several hours.

In addition to the immediate reaction the patient can react in the so called later phase, when the papules appear after several hours. The patient deducts and informs the doctor of the reaction by himself/herself. The skin tests represent the allergist diagnosis basis. Together with the detailed taken anamnesis they are sufficient for the majority of the patients sensitive to common inhalation allergens for the typical symptoms of the diagnosis. Their role in the diagnosis is hence important, which relates to the fact that their preparation and realisation should be paid attention to.

The skin tests can be characterised as indirect provoking tests. They are called indirect, since their positives and negatives prove the sensitization of the human body. The presence of the specific IgE antibodies to applied allergen is proved on the skin without giving the information on the reactivity of the particular target organ (unless the target organ is the skin itself). Standard prick tests are used. They are made by the pharmaceutical companies, which prepare them according to the strict formulas. The content of all solutions with the allergens is diluted exactly together with the known analysed components of the particular chemical. The food allergens to the prick tests are chosen similar according to the patients. In the basic scale the eggs, nuts, milk and hesperidium should not be omitted. As far as the patient has not only a food allergy, but also the inhalational allergy, we add the cross reacting foodstuffs (birch-apple, Artemisia-celery, mites-crabs, latex-banana, etc.).

The professional airways allergic illnesses have increasing tendency. The allergens are represented by the whole range of various factors of both, the vegetable and animal origin, but also by the chemical agents. Besides the pharmacotherapy, which does not differ from the common recommended procedures, the fundamental step is the immediate transfer of the patient from the exposition of the cause, which is necessary to be defined. To the testing process the chemicals, which are not tested with the traditional patients, are added, as well.

The contact allergy diagnosis skin tests are made by putting the analysed chemical on the skin. More information is provided in the chapter about the contact allergy.

The laboratory tests are the necessary part of the diagnosis procedure, in the case that the previous examinations were not sufficient for the unambiguous conclusion. The important restriction of these tests is the fact that the patient’s allergic reaction includes different cells in different tissues of the high degree of the variability. Even in the case of the same patient the ability to react can change in a short period of time. For the sake of the laboratory examination the blood is necessary. The blood collecting is usually made in the morning. If we undergo the blood collecting, we will have to take into consideration that it will contain the small amount of the elements, which are influences by the food we have eaten. Hence the blood collecting should be undertaken not only on an empty stomach, but even in during the last evening before the collecting, the patients do not have to eat a fair amount of the fatty meals.

The leukocyte differential calculus belongs to the basic laboratory examination. The medical finding of the eosinophilia is typical as for the allergic patients. To the standard examinations belongs the total IgE level examination. The values above 100 IU/ml state the allergic reaction (illness). A reliable source of information is provided in the newborn umbilical cord examination, where the higher level above 10IU/ml reflects the higher risk of the allergic illness during the life.

The specific examination, which proves the allergy and analyses the initialising allergen, is the specific IgE antibodies examination. Here, the antibodies, which react against the particular allergen, are looked for and determined.

All the IgE determining methods are demanding and require special devices, hence are made only in bigger centres. They are not made to all patients. They are needed in cases, when the previous examinations did not prove the clear diagnosis. Moreover, even more simple methods using the testing slips of paper similar to the litmus paper are used in order to diagnose the IgE antibodies quantitatively.

Before the allergist examination all allergic patients should have examined the basic biochemical parameters, which are necessary for the therapeutic preparations. When needed, if we suspect the nasal cavity inflammation or the asthma, sometimes the X-ray examination is made. The X-ray pictures of the head, eventually of the lungs, where inflammation changes can be observed, are judged. The lungs and nose function is judged through the spirometric examination.

Naso (the nose) manometry (blood pressure) is an examination, which measures the flow of rate of the nose. The measure principle is similar to the spirometry. Even the spirometer, to which a special attachment is added, is used.

A healthy nose is clear and a healthy person breathes usually through it (unless he exerts him/herself). If some illness process obstructs or restricts the flow of nasal rate, the patient breathes through the mouth even while resting, which brings many disadvantages (filtration restrictions and humidifying air, mucosa drying, etc.). Detailed information is provided in the chapter on common cold. The nasometry examination enables to objectify the seriousness of the measured numbers and the nasal obstruction. The patient himself does not have to know about the extent of the obstruction and the one, whose nose is obstructed for a longer period of time, usually does not know about it for sure, since he/she is used to it and thinks that everything is all right in the way it is.

While the nasal examination of both nostrils, two small devices with small hollows are inserted into the nostrils. The devices are connected to a tube, which the air flows in both ways, in and out, through. On the other hand, in comparison with the spirometry, the examined person has closed mouth and breathes only through the nose. One device (it looks like a small olive) is bunged up so that it does not allow breathing through the nostril the device is put in. The rate of flow of both nostrils is measured hence after the half time the devices are exchanged. In the same was as during the spirometry, the device records the air rate of flow of both nostrils and judges the congestion values. The examination is used not only for the common cold obstruction diagnosis, but also for the effect of the treatment evaluation. On more time, the patient himself often does not estimate the health improvement extent (“I can breathe through the nose easier”)

The medical finding of the total obstruction is not rare although the examined person does not know about it.

The first examination should be undergone without the medical treatment.

The therapy of the asthma has gone through relatively long development. It can be stated, that until recent times the patients suffering from the severe illness, dyspnoea (breathlessness) and choking, have been regarded quite common. The modern medication arsenal enables the patients – if it is used, disciplined and diagnosed correctly, to live the life with minimal or no troubles. The therapy must start on time! Delayed or neglected therapy relates to the continuing inflammation, to the gradual change and rebuild of the airways structure. It is more difficult to treat the anatomically changed windpipes and the therapy effect will not result in the absolute normalisation of the clinical conditions.

The asthma clinical symptoms are basically caused by two factors – the windpipes obstruction and the inflammation. The therapy is concentrated against those two processes, as well:

● bronchus dilatative (windpipes are expanding)

● antiphlogistic

The bronchus dilatative (bronchus – windpipes, dilatation – expanding) is a process of expanding (opening, enlarging) of the windpipes, which enables a better breathing. The medications used for this purpose belong to the basic asthma medications, yet they are taken even while suffering other windpipes contraction diseases. The medications are dosed according to the patient’s seriousness of the health conditions. They can be taken perorally (pills, syrup), injected or inhaled. Clinically they suppress the cough, the breathlessness and the whistling sounds. If they are dosed correctly, they enable the patients with contracted windpipes to breathe normally, without feeling sick. The medications are divided into – according to the effects principle several groups:

The basic group is the so called beta2 mimetics, also called betaagonists, which stimulate (irritate) the part of the autonomous vegetative nerve system with the result of released windpipes fibre muscles i.e. the windpipes extension.

The following side effects can occur, as well, although as for the modern medications they are rare:

● heartbeat and faster action

● short ague (especially hands)

● headache

● nervousness

The side effects result from the total medication influence, which effect in addition to the airways even other, especially cardiovascular system. The development of this type of medications is concentrated on the fact that the preparation should affect the airways the most and the other systems only minimal.

The best way to take the betamimetics is the inhalation. Hence many devices used to transfer the effective chemical to the needed place – the airways have been developed. If the preparation is liquid, the “small device”, which makes the aerosol from the liquid with the help of the driving gas, will be used. In this way the small medication particles get into the windpipes and the ronchus after the inhalation.

The second form is the powdered. The effective chemical is adjusted into the bin in the form of the powder and with the help of the ingenious mechanism while inhaling it is transferred into the particular target place. Both mentioned systems have their pluses and minuses.

The modern therapy uses two types of the beta2mimetics – effective for a longer or shorter period of time.

The short-term effective mimetics with the fast start are called the releasers. Their task is the windpipes spasm (cramp releasing). They are used if the patients can not breathe or if the health conditions get worse, since they are effective after several minutes. These medications are taken by the patients suffering from the intermittent asthma, since if the symptoms occur only once in a time (less than once a week), it will be the only therapy needed. If the breathlessness attacks appear oftener, the therapy has to be combined. Naturally, if needed, the patients suffering the severe disease undergo it, as well. Our market offers many preparations: salbutamol (SALAMOL, ECOSAL, VENTOLIN, and VENTODISKS), terbutaline (BRICANYL), fenoterole (BEROTEC also combined with the DITEC).

The long lasting betamimetics release the effective chemical gradually; hence they permanently affect the windpipes, which are extended under their influence. It is sufficient to take them twice a day. Together with the corticoids they are taken by the patients suffering from medium or severe asthma. Their effect start varies. There are salmeterol (SEREVEBT) and formoterol OXIS, FORADIL) used on our marketplace. The peroral betamimetics – either the pills or the syrup (terbitalin, prokaterol, bambuterol, klenbuterol) are used according to their systems side effects only rarely.

The anti-inflammatory therapy is based on the glucose-corticoids (cortisonides) taking, which are the hormonal preparations produced by the adrenal gland cortex (nowadays they are produces synthetically). They influence many levels and factors, which take part in the inflammation process. The best solution offers their local use – in the form of inhalation. The same devices as in the case of the betamimetics are used. In general, either injected or as pills, they are taken only in the most serious states of health. The doses are adapted to the seriousness of the illness. The informed patient can control their therapy to certain extent alone i.e. increase or reduce the doses according to their health conditions. The patient has to follow the criteria stated by his/her doctor.

We use: beclometozone (BECLAZONE, BECLOMET, BECODISKS, BECOTIDE, ECOBEC), budesonide (INFLAMMIDE, MILFONID, PULMICORT) fluzolide (BRONILIDE), flutikazone (FLIXOTIDE, FLIXOTIDE DISKUS), triamcinolone (AZMACORT).

From the point of the comfortableness and the effectiveness (anti-inflammatory and bronchodilative function) the combined preparations belong to the newest preparations. They are usually taken twice in a day. The corticoid element doses are taken according to the seriousness of the clinical health conditions. The Slovak market has two anti inflammatory and bronchodilative preparations at disposal: SERETIDE DISKUS and SYMBICORT. The modern preparations are the so called antileucotriens – the medications, which influence the molecular structure of the allergic inflammation process. These include sappirelukast (ACCOLATE) and montelukast (SINGULAIR), which are applied orally. In additions to these, the rommoglycolates in the inhalation form are used while treating the asthma. As for their advantage, they hardly have any side effects; their disadvantage is the often application (4-6 times a day). Considering the children they are very effective, their influence is restricted concerning the adults. There can be CROMOBENE, CROMOLYN, INTALCROMOGEN and nedopfromol (TILADE) found in our pharmacies.

Additional therapy is provided with the parasympatoliticums – the ipratrophiumbromid (ATROVENT combined with the COMBIVENT). The antihistamines, especially if the asthma is combined with other allergic symptoms, will be used, as well. After the allergen is defined, the allergen vaccination follows (detailed information in next chapter).

The teopfyline preparations (Syntophiline and so on), can not be used in the modern therapy except for the preparations with slow releasing (UNI-DUR, THEO-DUR, TEOTARD)

Biting insects (for example mosquitoes) secretions cause the local reactions as swelling and itching, although severe reactions happen only from time to time.

The biting insects comprise one of the most common causes of large or even global reactions.

All biting insects belong to the Hymenoptera species. We include bees, wasps and ants to this group.

The majority of the people react with bigger or small swelling of the area, where the stringer goes through the skin. In case of the multiple stings i.e. children bitten up to 50 times, even the global toxic reaction can be initiated as a result of the toxin effect.

That can not be applied to the allergy sufferers. After the venom follicle content, which is situated near the stinger, releases the toxins, the allergic reaction starts. This reaction is as serious as often the patient was bitten and hence sensitised.

The toxin structure of the Hymenoptera species is well analysed. The allergen is formed by a complicated mixture. It is interesting that bees, wasps and ants have one part of the toxin similar in the structure and another different. It means that the patient, who suffers an allergy to bee toxin can, but does not have to be allergic to wasp toxin and vice versa

The decorative plants were grown in Asia even two thousand years before. This custom was established in Europe later. The majority of the foliage plants, which is grown nowadays, came from Asia, as well – the tulips from Persia, the chrysanthemums from Japan, the primroses from China.

The fact that the foliage plants can cause the allergic reactions is known for years. Affected are professional plants growers, but also people, who care for these plants in their gardens and households – as their hobby.

In addition to problems with breathing – common cold, asthma, the decorative plants cause the allergies appearing on the skin and eyes, as well. The so called irritating skin reactions, which are caused by skin irritation by different matters contained in the plants, are not considered rare.

A significant role is played by the photocontact dermatitis. It is a reaction, which appears after the skin contacts the plant and is exposed to the sunlight later on.

After the contact allergic reaction the typical skin inflammation can be observed on hands and face, but elsewhere, as well.

The most common reaction is caused by the asterid plant – gerberas, chrysanthemums and daisy. Any part of the plant can cause the allergy, since they consist of the chemical substances – lactones, which more than 250 kind have been defined. They are contained in the cultivated foliage plants, as well as in the wild-growing ones (arnica, daisy and yarrow).

The chrysanthemums are considered the most significant plant from the point of the inhalation plants allergies. There is a cross reaction between the aster type genus plants.

The tulips often cause especially the skin allergy reactions. The professional skin reaction called tulip finger is well known particularly in Holland and touches the tulips sellers and .

The well known flower, which causes the contact allergy, is the primrose. The allergy is caused by the plant component primin, which is regarded a strong allergen concerning both, people and animals.

The plants growing in the plant pots are considered to be a safe alternative for the people suffering plant allergy. The reverse is true. Spatiphilium – glossy common plant with white flowers – has got pollen, which often causes the inhalation allergy. The rubber plant (ficus) – other favourite house plant – usually causes the allergy, as well. Besides, both contain the toxic calciumoxalate, which causes digesting troubles and bleeding after being consumed.

Whether at home or work we need to respect certain hygienic rules while working with the plants. Washing of those parts of the body, which came into contact with the plants should be natural. It is recommended to protect you with clothes and gloves, as well. The important thing is also the protection from the scratching or injuring, which increase the allergy possibility after the contact with the plant.

The people, who are busy with the plants and flowers growing professionally – gardeners, growers, sellers, decorators put themselves at high risk of the allergy start or development. Many of them are therefore forced to change their occupation. If they start to suffer from the allergy, no choice except for the occupation change remains.

Plants which are not suitable for growing

Parietaria judaica

is a weed, which commonly grows in gardens. It is regarded a common allergen as for its pollen. Hence it should be removed.

Ivy

which grows on the walls and in pots, has got many various colour types. It comprises toxic saponins and initiates even the contact allergy. Although it is regarded a type of weed, it is left in the gardens because of its nice colour. If we are allergic to this plant, we need to remove carefully (better with the gloves).

Cactuses and succulents

belong to favourite plants, but because of their thorns they are considered to be dangerous, especially for the children.

Angel’s trumpets (brugmansia)

are beautiful, but poisonous foliage plants. Their flowers can cause hallucinations and consciousness disorders.

Oleander (Nerium oleander)

All plants are poison. Fortunately, their taste is disgusting. The manipulation requires gloves and proper hands washing. It consists of irritating saponins.

Amaryllis

has poisonous bulbs, which can be mistaken for onion bulbs by children.

Digitalis

contains cardiac stimulants. However their usage can break the heart rhythm.

Azalea

is poisonous. It is dangerous to farm animals (sheep, goats, cattle), which dies after eating it.

Many flowers and plants, which we grow at home or in our garden, are very risky to up – especially considering the children since during their early age they put almost everything, which they came into contact with, into their mouth. The colourful flowers of interesting shapes are luring them. We need to be aware of it and hence protect them from such a contact with the toxic plants.