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Are you sure you’re allergic to penicillin?

As a pharmacist, when I dispense medication, it’s my responsibility to ensure that the medication is safe and appropriate for the patient. There are numerous checks we go through including verifying the dose, ensuring there are no interactions with other drugs, and verifying the patient has no history of allergy to the product prescribed. Asking about allergies is a mandatory question for every new patient.

Penicillin is one of the oldest antibiotics still in use despite widespread bacterial resistance. Multiple analogs of penicillin have been developed to change its effectiveness, or improve its tolerability. And other classes of antibiotics (e.g., cephalosporins) share some structural features with penicillin. These products are widely used for both routine and serious bacterial infections. Unfortunately, allergies to penicillin are widely reported. Statistically, one in ten of you reading this post will respond that you’re allergic to penicillin. Yet the incidence of anaphylaxis to penicillin is estimated to be only 1 to 5 per 10,000. So why do so many people believe they’re allergic to penicillin? Much of it comes down to how we define “allergy.”

Adverse Events, Reactions, and Allergies

There are a number of confounders when it comes to evaluating allergies. A big one is terminology. While different groups vary in their definitions, the term “adverse drug event” typically means that an undesirable event has occurred, but isn’t causally linked to the consumption of a drug. In contrast, “adverse drug reaction” is usually reserved to where a causal link to the drug has been established, or is fairly certain. Adverse drug reactions can occur under completely normal use of a drug. And they’re not uncommon, as I’ve pointed out before. An allergic reaction to a drug is an adverse drug reaction that is mediated by an immune response. If there is no immune response, it’s not an allergic reaction. So if you take codeine and it makes you drowsy and constipated, that’s not an allergic reaction—that’s an effect of the drug. Erythromycin commonly causes stomach upset, so if you vomit, that’s not an allergy either. So, to sum:

Penicillin Allergies

Within that box of adverse reactions we’re calling “drug allergies” there’s a number of methods of classifying the different immune responses. The most common way is to split events into immunoglobulin E (IgE)–mediated (immediate) reactions, or non–IgE-mediated (delayed) hypersensitivity reactions. The IgE-mediated reactions are the ones we might immediately think of when we hear “penicillin allergy”: flushing, itchy skin, wheezing, vomiting, throat swelling, and even anaphylaxis. These reactions can occur immediately to a few hours after a dose. The non-IgE-mediated reactions are delayed, and can be mild or severe, ranging from serum sickness to the horrific (but fortunately rare) Stevens-Johnson syndrome.

Skin rash (morbilliform eruptions) are non-IgE reactions commonly reported with penicillin therapy, though their relationship to the penicillin itself isn’t clear. Rashes that appears several days after starting therapy (or even after finishing a course of antibiotics) may be due to a poorly-understood relationship between the antibiotic and any concurrent viral infection. These rashes are not itchy. With subsequent exposure to penicillin (or a related drug) the rash can reappear. These types of reactions do not mean that one cannot receive penicillin again, however.

It’s the structure of the penicillin molecule itself that triggers allergic reactions. Both the “parent” drug and any iterations created through metabolism can induce allergic responses. Analogs of penicillin, with different molecular side chains, can trigger selective sensitivity in some. So one could have an allergic reaction to amoxicillin or ampicillin, but be able to tolerate penicillin.

Testing for allergies

Determining if you’re actually allergic to penicillin is important to sort out, as not all reactions mean penicillin cannot be administered again. Skin testing is the standard for testing for IgE-mediated allergies, and needs to be performed under medical supervision, usually by allergy specialists, in settings where access to resuscitation medication is available. Given the unreliability of memory, skin testing is the standard when there’s any doubt at all about the type of prior reaction. In cases of the severe non-Ig-E type reactions, there’s no rechallenge attempted, and those patients should never receive penicillins again.

So if you think you’re allergic to penicillin, but are not certain of the type of allergy you have, testing is something worth thinking about. Without it, you’re setting yourself up for a lifetime of risk and consequences of the avoidance of penicillin. Data show that patients considered penicillin-allergic will typically receive more broad-spectrum antibiotics, which may have more side effects, be more expensive, and in some situations, less effective. And given IgE-mediated allergy can wane over time, even significant childhood reactions may not manifest as adult allergies—but only testing can determine this for certain.

Formal evaluations of penicillin allergies support this approach. A recent paper in the Journal of Allergy and Clinical Immunology describes a prospective evaluation of children that presented to an emergency room with a delayed-onset rash from penicillin. Eighty-eight children were enrolled over two years. At the time of enrollment, they were screened for viruses. Each child returned to the hospital two months after their initial visit, where they underwent skin (patch and intradermal) as well as blood evaluations for allergy. They all had an oral challenge with the original antibiotic, too. After evaluation, none had a positive skin test, 11 children (12.5%) had a intradermal reaction, and only six (6.8%) had the rash recur after an oral challenge. Within the group that had a positive oral challenge, two had intradermal-negative, and one was intradermal-positive. Most of the children had tested positive for viral infections, too.

The authors concluded that penicillin allergies are overdiagnosed, and viral infections may be a factor leading to rashes and over-diagnosis. The authors recommended oral challenges, rather than skin, intradermal, or blood tests for all children that develop delayed-onset rashes during treatment with penicillins.

Conclusion

While penicillin allergies can be real, and can be serious, only a small percentage of people that consider themselves allergic actually cannot receive penicillin. Avoiding penicillin can mean using antibiotic alternatives that are less effective, more expensive, and have greater side effects. For this reason, confirming a penicillin allergy with a physician is warranted—before an antibiotic is needed. After all, unless it’s necessary, you don’t want to end up with someone like Mark Crislip standing over your hospital bed, being asked what his second choice of antibiotic is going to be.

Reference

Caubet JC, Kaiser L, Lemaître B, Fellay B, Gervaix A, & Eigenmann PA (2011). The role of penicillin in benign skin rashes in childhood: a prospective study based on drug rechallenge. The Journal of allergy and clinical immunology, 127 (1), 218-22 PMID: 21035175

Posted in: Basic Science

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50 thoughts on “Are you sure you’re allergic to penicillin?

  1. stopthatastronaut says:

    I do have a related question.

    Penicillin being penicillin, is it possible that some penicillin-allergies can be triggered by the penicillium molds in blue cheese? I find it plausible, and I’ve been diagnosed (as an infant) with penicillin reactions. “Allergic to penicillin” has been on my file ever since.

    Anecdotally, I’ve got mild skin irritation *after* blue cheese, but post-hoc ergo propter-hoc and all that.

    I’ve also had fairly bad stomach aches after peanuts but I don’t claim to be allergic to them, because usually I only eat peanuts if I’m drinking beer, and usually salty peanuts make me drink more beer… and… you get the picture.

    So, could blue cheese trigger a reaction? Or is there some post-hoc and confirmation bias operating here?

  2. lillym says:

    I have personal experience with this, when I was about 13 I was taking penicillin and broke out in hives. And I never questioend if I was truly allergic, I just accepted it.

    Then I had an adverse reaction to sulfa antibiotics – I didn’t get hives, but I had a reaction. So now that got marked on my chart – allergic to sulfa.

    Oh and I had an adverse reaction to Cipro (not allergic reaction but both times I took it I started having extreme joint/tendon pain) so they wouldn’t give them.

    And when I was a toddler I broke out in hives when I was given Macrodantin – I have a history of UTIs and had surgery to correct bladder reflux as a toddler.

    Then last year I had a whole medical drama with UTIs and ended up on Gentamicin via IV 2x a day for 7 days. Twice.

    It wasn’t until right before the second time anyone suggested I might want to get tested to see if I was really allergic (and due to scheduling issues I had to wait until after the treatment).

    Turns out – Not allergic to penicillin!

  3. windriven says:

    “And given IgE-mediated allergy can wane over time”

    Interesting. I infer from this that non-IgE-mediated allergy is forever.

    Can anyone enlighten me as to why genetically based IgE-mediated responses can vary over one’s lifetime while non-IgE-mediated responses apparently do not? This is counterintuitive to me.

    Also, can anyone tell me from whence non-IgE-mediated responses arise?

    Please excuse my ignorance; biology is not my science.

  4. Kylara says:

    My toddler broke out in the delayed-onset penicillin rash and it was scary as shit, because it just LOOKS horrific and it was his first antibiotic course ever. They marked him as “allergic” in his file at both the doctor AND the pharmacy, but the doctor did tell me when he was five or so we would try penicillin again because many little kids “grow out of it.”

    (We are STILL treating the dry-skin patches that are the remnants of the rash, it’s a really terrible rash!)

    Regarding other reactions, at what point do you say, “My reaction is so bad I shouldn’t take that antibiotic?” Erythromycin for a bad bout of upper respiratory infection made me so sick I threw up for like 10 straight hours and had to get fluids and spent longer recovering from the stomach upset and subsequent dehydration than from the (antibiotic-treated) URI! So, like, probably I should cross that one off my list? But when I tell doctors I won’t take it, they always mark me as “allergic” on my chart, rather than “intolerant” or “reacts badly” or something like that.

  5. hmm – interesting. My husband’s report states that he is allergic to penicillin due to a childhood rash reported by his mom.

    The thing is, we have begun to suspect that he gets hives in response to virus exposure. When he had an outbreak of very bad hives shortly before he had mono about 7 years ago. He had a second bad outbreak of hives a few years ago, that was completely mysterious, as far as we could figure, we hadn’t done anything out the ordinary to expose him to a food or drug allergen. I find the hives rather frightening, since they come on quickly, tend to cover his arms, leg and trunk and benedryl doesn’t make a dent in them. Luckily, prednisone does work for him. Of course, my fear is nothing compared to his itchiness.

    I’m curious, if anyone knows, what the oral challenge allergy test like. Is the allergy response small, as is typical in skin testing or do you get a full blown reaction? I might mention it to him as an option. Might be good to have penicillin available to him, if he is not actually allergic to it.

  6. Recovering Cam User says:

    Thank you for this post. This has been an ongoing question for me since I was given amoxicillen for a supposed strep infection when I was 18. After I broke out in itchy red bumps, it was determined I actually had mono, and that this reaction was so common it was called “the poor man’s mono test.”

    In the intervening years, I’ve asked no fewer than half a dozen doctors if I actually am allergic to amoxicillen – some said yes, some said no, but most had no idea. Given that my mono evolved into a long term case of CFIDS with occasional documented EBV flare-ups, it sounds like I may have a higher than average chance of having that reaction again. But I’m glad to know there is a test I can take to help sort that out.

  7. lillym says:

    michele- the testing I had done had three parts and if you had a reaction to any of the parts they stopped the test.

    The first part was skin test on my arm, I didn’t have a reaction so they went to the skin test on my back. When I didn’t have a reaction that they gave me a small dose of penicilin to swallow.

    When I didn’t have a reaction to that I was declared not to be allergic.

    If I’d had a reaction to the skin test they would have stopped and I would have been allergic.

    The whole thing took a few hours but it was worth it.

  8. Watcher says:

    Well, I’m totally confused about my allergy now. My primary care doctor and I decided to try out Amoxicillin when i was in my early 20′s (5-6 years ago), as my parents had always told him and I that I had a penicillin allergy. My hands swelled up and started itching one night about 5 days into the treatment, by the next day it had started on my feet and was creeping up my arms. Needless to say at that point I stopped taking the antibiotic. It took about a day for the swelling and itching to go down.

    From the description above, I can’t really tell which type of response this is.

  9. My son had a red rash that developed a few days into treatment with cephalosporin, but he has taken penicillin and augmentin without incident. I don’t know that I’d call his cephalosporin rash a true allergic reaction, but that’s how his pediatrician put it down in his chart– I guess to be safe rather than sorry? With today’s focus on defensive medicine, I imagine most docs just label the kid as allergic and move on to a different treatment when a rash shows up, especially when the child is too young for effective allergy-testing.

  10. jre says:

    This post was not just enlightening, but immediately and personally useful. All my life, I have told anyone who asked that I was allergic to penicillin — simply because, many years ago, my parents told me that I was. Now, as a result of reading this post, I am considering an allergy test. I don’t remember my childhood experience with penicillin. I have never had any adverse reaction, immediate or delayed, to any antibiotic. My wife says that I would probably eat newspaper if it had blue cheese on it. And I definitely don’t want to see Mark Crislip being consulted about my case, because I am allergic to smart-ass remarks.

  11. lillym – thanks! Although getting my husband to take 3 or 4 hours off work to see an allergist might cause him to break out in hives…:)

  12. mikerattlesnake says:

    When I had my appendix out (keep in mind it was a more invasive procedure than usual, my appendix was tucked behind my other guts so they had to split me open) I had a reaction to the penicillin. I had a rash around the wound that was extremely itchy and started to spread to the rest of my body. I was listed as “allergic to penicillin” and changed drugs. When I switched antibiotics the rash went away. I know the purpose of this site/comments is not to diagnose, but I am left unclear about which category I fall into. Should I get retested? I’d rather have penicillin available to me for the reasons you listed.

  13. tuck says:

    What a great post.

    Like many of the other commenters, I’ve had reactions to penicillin, amoxycillin, and sulfa drugs. I’ve therefore been told I’m allergic…

    Sounds like a retest is in order.

  14. Chris says:

    My father was hospitalized with a reaction to penicillin. We were traveling, and it started with a rash just before we boarded the plane. After the flight, the people who picked us up from the airport took our family to lunch. That was when my father started to swell up, and he was taken to the hospital. When we visited him the next day he looked like the Michelin man with a rash.

    Since then my step-mother decided that if my dad had the allergy, the rest of us kids did to. So she never let us have penicillin. I don’t know what I took later that year when I had pneumonia, but it was not penicillin.

    My oldest son has a heart condition and takes amoxicillen before dental appointments. So far he has been fine.

  15. Scott says:

    It’s kind of interesting to see how different doctors react to being told that there’s a history of penicillin allergy in the family. A severe one – as in anaphylaxis and almost dying. Various doctors have variously told me “it doesn’t matter,” “probably you’d be OK, but we’ll use something else to be safe,” and “you should tell people you yourself are allergic.” Never did understand the last one. Especially since one of the doctors in the first category gave it to me, without reaction, and the one who said it knew that.

  16. nybgrus says:

    @windriven:

    There are 4 classes of hypersensitivity reactions – I, II, III, IV (yep, very straightforward there).

    Type I: IgE mediated and immediate to rapid onset (anaphylaxis)
    Type II: cytotoxic/antibody-dependent (IgG or IgM) which takes hour to days for onset.
    Type III: Immune complex deposition (of which serum sickness is a type).
    Type IV: Delayed hypersensitivity – activated the adaptive immunity and a T-cell response

    Type I is a mast cell degranulation issue and if you no longer have the IgE production for that specific antigen (or a decrease of it) then you will not have a reaction anymore. Since the production of the IgE requires a specific pathway of B cell stimulation to be active, it is possible to have the immune biochemistry shift away from that and not form that B cell response to a re-challenge.

    For the others, the reaction actually follows a pathway of what is called “memory” cells. IgG is secreted by B cells as well, but when a B cell class-switches from IgM to IgG then a population of those B cells will become resident “memory” cells and migrate to the bone marrow and live there forever – this is the basis for immunizations (and forever can also just be a very long time as we know some immunizations need to be repeated every 10 years, but others are lifelong). Type IV activates the T cell response, which also form “memory” cells. IgE secreting populations do not form “memory” cells.

    I hope that answers your question.

  17. windriven says:

    @nybgrus

    Thank you, your explanation is clear and concise. That said, I’ll stick with physics ;-)

  18. Ray Greek MD says:

    Good post! Thanks!
    Just my 2 cents worth on this. As an anesthesiologist I saw a lot of charts with “Allergy to . . .” on them. The allergies ranged from “local anesthetics” to “Thorazine” to “general anesthesia” to “heart drugs.” I would inquire with the patient who would then give me a vague history of a bad reaction that may or may not have been drug-related. This is problematic as if you say you are allergic to something it will affect what drugs I give you and equally important, what drugs I do not give you. Some of those drugs are drugs you might want to have. But my hands are somewhat tied if there is a big note on your chart saying you are “allergic.” There are legal implications here too.
    As Gavuar points out, allergy is not the same as an adverse reaction or an adverse event. I am just saying that you should be pretty sure what your status is as there are cross allergies with other drugs and so forth so saying you have an “allergy to . . “ will influence your care. I am not saying to ignore or fail to mention allergies or even adverse drug reactions or events. Just try to make clear what you know and what you don’t know about your reactions.

  19. Noadi says:

    As someone who’s actually seen a real full allergic reaction to penicillin (my younger brother) I know it’s not a mild issue for those who are truly allergic. My brother could die if he has penicillin again and doesn’t get immediate treatment. It was really scary to see him covered in hives and having trouble breathing the first time he had a reaction, if my parents had waited much longer to take him to the ER it could have been much worse. The second time he was exposed to penicillin he spent 3 days in the hospital.

    Having a proper history and testing is very important. Not only for those who aren’t allergic who could benefit from the right antibiotics but also for those who are. The more certain doctors are of their patient’s allergies the less likely they are to give them a medication that will cause a reaction.

    I’m curious though about how often allergies like this can run in families? I wonder sometimes if I should avoid penicillin and related antibiotics just to be on the safe side or not?

  20. Bogeymama says:

    Great post Scott. Probably the most common “non-allergy” I get informed of is an allergy to codeine / morphine / insert narcotic here. In most cases, it turns out to have been nausea & vomiting. Of course, these patients are then perfectly fine to get T3′s??!! I am hoping that allergy-testing for penicillin becomes more mainstream. I was given an antibiotic when I was 4 years old called Trulfacillin (never heard of it … but my Mother was a nurse, and she remembered it). It was a combination of penicillin and triple sulfa. All I know is I ended up in the hospital with a severe reaction. I have gone through life assuming allergy to only 1 of them, but having to claim an allergy to both penicillin and sulfa. I imagine this might be the case for several 40 + year olds out there that may have suffered tonsillitis as a toddler. Hasn’t affected me yet, but with ready access to liquid penicillins, I’ve been tempted so give myself a skin test.

  21. mitdun says:

    So if I’m chemosensitive (asthmatic response to cigarette smoke and some perfumes and cleaning products, rash in presence of sulfa or formaldehyde), and my mom is too (entire NSAID class causes adverse reactions ranging from horrible edema to heartbeat irregularity; perfumes and aspartame give her migraines), what is the proper/fastest way to inform a medical professional properly? I tell them I’m careful about taking ANYTHING. If you say, “I’m allergic”, that ends the discussion and changes the prescription, but it may not be accurate. The real explanation could take more time than they have, especially in Mom’s case, if they want details for each substance. What should be done?

  22. superdave says:

    I just went through this exact routine trying to find an antibiotic to battle my strep throat. I had a mild rash at about age 10 or so the last time i had penicillin and since then I was told I was allergic so I just stopped. It seems like getting tested might be worth it for me since my reaction was pretty mild in the first place. However I have to ask, what are the chances of the allergy test giving a false negative?

  23. Jan Willem Nienhuys says:

    @ Ray Greek MD

    On Januari 1, 1972 my appendix had to be taken out in a hurry, and I was asked if I had allergies. Yes: asthma and I once got covered in red spots after getting sulfa. So the appendix was taken out under only local anesthesia. It hurt quite a lot, but I was wide awake when the operation was over.

  24. @Jan Willem Nienhuys

    I don’t understand. Why the need for local only? Was this the anesthesia drugs used in the 70′s? I’ve never heard of such a thing today.

  25. Jan Willem Nienhuys says:

    @ micheleinmichigan

    Don’t ask me. I guess they didn’t want to run any risk with a patient that would get some kind of violent reaction to the anesthetics (an asthma attack, who knows). And they must have felt there was no time to lose. It was well over 24 hours after onset of pain and cramps. So about a quarter of an hour after they had asked me I was wheeled into the operating room. It was in Taiwan.

  26. npoljak says:

    @mitdun

    Can aspartame really cause headaches or is it simply anecdotal?
    Have you or your mom kept a “headache diary” (as Steve recommends in his aspartame post) to rule out confirmation bias?

  27. Chris says:

    Dr. Greek, I used to think I was allergic to narcotics. Then I found out I just cannot tolerate them. It is no fun to have an ankle in a cast and trying to hobble to the bathroom to vomit.

    So when I had my colonoscopy, they gave me both the narcotic and anti-nausea medication. Worked just fine.

    I am allergic to lots of things from alder pollen to nickel. But so far, not any medications (that I know of).

  28. Harriet Hall says:

    npoljak,

    A study published in the NEJM showed that people who thought aspartame gave them headaches couldn’t distinguish between aspartame and placebo.

    http://www.nejm.org/doi/full/10.1056/NEJM198711053171903

  29. npoljak “Can aspartame really cause headaches or is it simply anecdotal?”

    From Steven Novella’s Article
    “A separate question is whether or not aspartame causes headaches in some people. While there is not a lot of specific data on this, there are case reports of aspartame triggering migraines in susceptible people. Migraineurs frequently have multiple food triggers, and there is a long list of foods known to be potential migraine triggers.” etc

    http://www.sciencebasedmedicine.org/?p=6822#more-6822

    Here’s my question. If you get migraines, which cause you to have to lay still in a dark room for a number of hours until the pain is so bad that you throw up and you suspect that a certain non-essential additive such as aspartame* triggers them, Is it really important enough to run a series of tests to prove that particular trigger?

    It good to understand that keeping a food diary can be helpful, but migraine triggers can be multifaceted. Hormonal shifts, sleep patterns, temperature changes have also been reported as migraine triggers. It’s unlikely that one is going to be able to completely eliminate confirmation bias or prove the existence of a migraine trigger in one individual with the information available today.

    Of course, that’s just IMO and only based on having a sister, father and mother-in-law that suffer(ed) from migraines.

    *Now if the suspected trigger were something essential like chocolate or red wine…it might actually be worth the test. :)

  30. mitdun says:

    Mom drank diet sodas almost constantly for 2 years and developed horrid migraines. After a neurologist told her they were incurable, and put her on a terrible drug that she only took once, she tried an elimination diet. She strategically eliminated and added foods and drinks until she figured it out. A small glass of sugar-free punch or a dessert at a church potluck made with the stuff is still enough to lay her flat for 2-3 days. She is migraine-free as long as she avoids her triggers. She is weird, though- Vioxx made her legs swell like an elephantiasis victim. Her orthopedic specialist did not believe her until he saw it for himself. When I say chemo-sensitive, I mean chemo-sensitive.

  31. Harriet Hall, I’m confused. I thought that medicine distinguished between migraines and other types of headache. Your link appears to suggest that the test was done on people with unspecified “headache” after aspartame. Was this test actually done on migraine suffers? My apologies, I don’t understand the tests they cover. That might clarify it for me.

  32. Harriet Hall says:

    @ micheleinmichigan

    The study in question said that the subjects’ headaches were classifed by a neurologist as “vascular headaches,” which is not the preferred term today but is consistent with migraine headaches.

  33. micheleinmichigan: the aspartame/migraines fascinates me. After seeing this entry by Scott, I talked with my Pharmacist (Scott might know everything but he doesn’t sell Homeopathy so you can’t really trust him ;-) ) and he said that many people claim that aspartame causes migraines but he, too, suggested the link is tenous at best. He said that from what he had read, it is only when someone tastes the “aftertaste” or is aware that they are ingesting aspartame (not as you’d suspect if it were a true “trigger”).

    He related a major study (n=1) to me – his brother claimed aspartame triggered migraines and my pharmacist friend gave him a placebo claiming it was a stronger version of what he was taking. It worked for his aspartame triggered migraines. (It doesn’t, however, work for his anxiety related migraines!)

    After having explained it to his brother, aspartame doesn’t trigger his migraines (he still isn’t keen on the aftertaste, though) – which I don’t find to be the common reaction. (Expose an ion foot cleanse to someone and they become further entrenched in the crazy belief!)

    I was certain that I had allergies (specific ones) and went through an allergy test and it determined I’m not allergic to (really) anything. Since then, I haven’t had “reactions” – so I guess I’m not even “sensitive” to those things. Wanting something to be true doesn’t make it so, I guess. (Those tests and my discovery lead me on my skeptical journey so I guess it wasn’t all for nothing.)

    Now… what can I take to deal with my allergy to needles?

  34. mitdun says:

    Mom does not have to know she has ingested aspartame. She will eat or drink something, then develop the headache, realizing the presence of the stuff only when the headache hits. She does not drink punch now unless she knows the source.
    I know people get skeptical about hypersensitivity, but I’ve had enough freaky rashes (dissected “formaldehyde free” frogs once with my seventh graders, and had skin covered in itchy red bumps from my glove line to my elbows- they had been initially preserved in formaldehyde, and shipped in another compound) and violent coughing episodes (I’m a human smoke detector- third-hand smoke in an elevator from a person’s clothing can set me off) to avoid my triggers pretty carefully whenever possible.
    I know which antibiotics/drugs/chemicals caused problems so far, and alert doctors to those. Maybe I should be tested for the sulfa allergy, as it has been several years since that rash. But with the possibility of an asthmatic response, I just don’t take chances. I like breathing.

    1. Harriet Hall says:

      mitdun said “Mom does not have to know she has ingested aspartame. She will eat or drink something, then develop the headache, realizing the presence of the stuff only when the headache hits. She does not drink punch now unless she knows the source.”

      As a Devil’s advocate, I would want to know if there was a possibility that Mom had unwittingly ingested aspartame on other occasions without developing a headache. Could her conclusions be a result of confirmation bias? A properly blinded N=1 trial would be more convincing.

  35. nybgrus says:

    @ windriven:

    You’re welcome. And physics is cool. Especially when applied to medicine (like MRI) :-)

  36. “He related a major study (n=1) to me – his brother claimed aspartame triggered migraines and my pharmacist friend gave him a placebo claiming it was a stronger version of what he was taking. It worked for his aspartame triggered migraines. (It doesn’t, however, work for his anxiety related migraines!) ”

    Hmm, so your pharmacist ran an experiment on his brother without his permission, by misrepresenting the product he was suggesting, thereby “proving” that said brother doesn’t actually react to aspartame, but leaving the brother without the appropriate medication to prevent migraines caused by other triggers, such as anxiety. Which, I imagine, left the same brother laid-up with intense pain, possibly until he vomited, for at least one day.

    I don’t know whether to be bemused at the nature of family relationships or that you trust this pharmacist, because he doesn’t sell homeopathy.

    Sometime I think folks get so caught up in the glorious fight against woo or following what the research currently suggests, that they forget the human element.

    It seems to me, mitdun asked for advice on communicating a reaction to medication or environmental trigger to a Doctor without misrepresenting it as a allergy. Instead of actually attempting to help with the problem, folks want him to prove that said reaction/trigger is actually happening. Nobody responding even made an attempt to suggest why if might be worthwhile to risk the migraine or asthma attack to more clearly separate some assumed triggers from true triggers.

    Skepticism is fine, but knee jerk skepticism without an actual goal or thought as to how that skepticism is communicated or the feeling of the recipient, may be counterproductive, not to mention annoying as heck.

  37. “I was certain that I had allergies (specific ones) and went through an allergy test and it determined I’m not allergic to (really) anything. Since then, I haven’t had “reactions” – so I guess I’m not even “sensitive” to those things. Wanting something to be true doesn’t make it so, I guess. ”

    Actually, this is funny, because I also thought I had allergies. Went to the allergist for chronic sinusitis and very irritated eyes . Turns out I also don’t have allergies. Sadly, unlike you, I still had the chronic sinusitis and the very irritated eyes. The only relief that the allergy tests provided was that I wouldn’t have to worry about getting rid of the cats anymore.

    By the fourth trip to another doctor, I found out that my eyes are dryer than normal (thyroid related). So many things that throw particles into the air (pollen, dust) irritate my eyes because of lack of moisture rather than allergies (this is a simplification of the actual issues). Still don’t really know about the sinusitis, maybe some kind SBMer will replace my flonase and zyrtec with a placebo in the attempt to prove I don’t need them. :)

    Regardless, I can appreciate the need for doctors to suss out actual causes. But, I think that should be done with some sensitivity and attention to detail.

  38. Narad says:

    Very enlightening post. My mother sent me off to college many years ago with the admonition that I was allergic to erythromycin. I dutifully report this, at every single visit, to the nurse who asks while taking my BP. Only on the few occasions I’ve been asked “What happens when you get erythromycin?” do I flesh out the story with “beats me.” Nobody has ever suggested rechecking.

    I did break out into a trunk-arms-and-thighs rash a week into a course of Bactrim not too long ago (heralded by insanely itchy feet; I digress), though, and this seems to get lumped under “allergic to” whenever antibiotics come up. I’m hoping it’s more a convenient way of talking than an actual mistake.

  39. mitdun says:

    Harriet,
    For the first year or so, when Mom drank diet sodas, she was OK. Then the headaches started. After that, every known time she had a migraine, if we called the person who made the Kool-ade at church VBS or the punch at the wedding, he/she would say, “Oh, I’m so sorry, it was sugar free… yes, it had Nutra-sweet. Sorry.” For home consumption, she avoids it completely. At church functions, she now consumes only unsweetened tea or water, and skips the dessert table, so I’m fairly sure she does not contact it. She has consumed Splenda, and so far it is OK. Could be confirmation bias, but still not worth the re-test, considering that she has been migraine-free for years.
    We are from a family full of medical oddity. We have both had physicians, more than once, say “Good God! I’ve never seen that before!” during an exam or looking at a chart. It’s worse when they look puzzled, leave the room, get an older doc, and the OLDER one says that (Happened to Mom during an eye exam with an opthalmologist- she’s a platinum blonde with pale blue eyes and unusual retinal pigmentation, so it looks like blood is pooling at the back of her eyes. Her regular opthalmologist says it is OK.). I would not say aspartame causes headaches for everyone, or should be pulled off the market. We are just weird, and we accept that.

  40. Kultakutri says:

    I sort of understand that for purposes of simplification, people use the term allergy for other sensitivities/intolerances. I know that my reaction to tetracyclin isn’t an allergy but puking until I passed out and my family needed to call the ambulance because I was dehydrated and exhausted and couldn’t just lift myself from the toilet bowl is bad enough to be a reason to avoid the drug group. And, well, if ‘allergy’ is a shorthand for Patient shouldn’t be given this, I’m fine with it. I was explained that it should be differentiated because under some conditions, the disease might be worse than cure and then they’d deal with the terrible stomach upset otherwise but for a random URI, it doesn’t matter that much how my inability to stand tetracyclin is defined.
    I have asthma and I find a large list of stuff irritating even if I’m not allergic to it. Again, I say that I’m allergic to cigarette smoke, people know what allergic is and it’s shorter if innacurate than describing that, well, I have asthma and I’m sensitive to things and cigarette smoke makes me cough, which is uncomfortable.To which smoking fellow citizens respond Oh, fine, we’ll move the ashtray ten centimetres further from you, or more often, You’re a sissy. For purposes outside the medical setting, it doesn’t matter whether I’m allergic to milk or whether it’s lactose intolerance.
    I’m truly allergic to penicillin – the last encounter caused hives, fancy swellings and purple spots all over my surface and my ENT wanted to keep me in the hospital for monitoring; I only escaped by promising that I’ll come for calcium shots daily and that I’ll call the ambulance immediately if I thought my throat was swelling. And to macrolids that result in itchy oozy rash. My wonderful cynical ENT doc looked on my inflamed larynx pensively and then called the whole deparment to have a look at oozy rash inside my throat. It is sort of funny… but only sort of indeed.

  41. Bogeymama says:

    “For purposes outside the medical setting, it doesn’t matter whether I’m allergic to milk or whether it’s lactose intolerance.”

    Actually, this matters very much. There are so many people out there now that claim an allergy to milk, due to the popularity of the WFCF diets to try to control behaviour in children (future topic of discussion??), and the increase in labs allowing self-referral for IgG testing, which almost always show positives for milk – but aren’t necessarily true allergies.

    My son actually has an anaphlactic allergy to milk. We know of 3 teens that have passed away from allergic reactions to milk in the past few years just in our area. It is not as uncommon as you might think. The general public believes that this is only likely to happen with peanut. While things are better now, it was difficult getting the schools and other parents to understand this. More often than not, when I explain about his milk allergy, people think it has something to do with his behaviour, or that he simply has a lactose intolerance and he could be very uncomfortable if he were to accidentally consume milk. Once I started figuring out that I needed to explain it in terms of a peanut allergy (he could actually die from exposure to milk) only then did people start to get it. We have a new principal and he admitted to me last week that he had never heard of an allergy to milk. So now I get to start all over again.

    The distinction is very important for the kids with true allergies in order to get the people in charge to take it seriously. It really muddies the waters when some kids claim an allergy to milk, and yet are given the green light to consume treats at school without need for permission from home. My son is allergic to nuts as well, but in 10 1/2 years he has never had an accidental exposure. Milk is so much harder to control for… We recently tried to get him into a study at Mt Sinai in New York looking at potentially curing a milk allergy through gradual exposure through baked milk, but his allergy was deemed too severe. In case you think it’s not possible, his worst reaction was from a single bite of a hot dog, given to him at a public event. Casein protein is used in some hot dogs … but the label didn’t show it. We guessed that there must have been 2 brands used, and they showed us the wrong label.

    So don’t be offended when people in the pharmacy / medical world, or even restaurants and teachers, start asking for clarification of your allergy. It really does matter, in terms of potential treatments or how food is prepared, what has happened to you in the past.

  42. murder_city says:

    I’ve been a nurse for 30 years, and it amazes me how drug side effects have become “allergies.”

    Way back when, drug allergies usually consisted of only a few, common bogeymen, e.g. penicillin, sulfa, aspirin, iodine, lactose, dyes, opiates, etc.

    Now patients say they have allergies to all kinds of drugs. When asked what their allergy symptoms consist of, almost always what they are describing are side effects(not to be confused with adverse reactions) of the drug, which frequently will dissipate over time.

    Physicians seem reluctant to instruct patients that side effects usually dissipate and when they are confronted with patient complaints of side effects, they simply put them on something else.

    The patient then believes they have an “allergy,” and they go to another clinician later and say they are allergic to the drug. Often nobody questions it.

    This seems to have given rise to the idea that drugs shouldn’t have any side effects, so when some patients experience side effects, they think they have an allergy, and the cycle continues.

  43. It sounds to me like all those forms you fill out at the doctor’s, dentists and pre-op could be slightly revised. (I know, like we need longer forms.)

    Instead of the request to list drug allergies, perhaps we should have something like this.

    Please list drugs or medical product that you have had a {something}* reaction to.
    Item One. _____
    Did this reaction include?
    A. Hives, facial swelling, etc.
    B. Nausea or vomiting, etc.
    C. Breathing symptoms
    D. Other _________

    Item Two.______
    (repeat items as in item 1, etc)

    I’ll leave it up to the medical folks to what short description should be in the A. B. C. etc list.

    *I’m not sure what word to use, adverse doesn’t seem correct, unpleasant is too mild…?

  44. Here’s one of my non-allergy concerns. At one point I was a little concerned my son might be having a dermatitis reaction to latex*

    With time and consultation with our doctor, we feel pretty comfortable thinking he does not have an allergy to latex, it is more likely a reaction to adhesive and the dental work itself. BUT while researching the latex I found out that people who have multiple surgeries (as he has and will have) as children are more likely to develop latex allergies. So, I’d just prefer that whenever safely possible health care worker use non latex products in surgery, examining mouth, dental work, etc.

    So now, I don’t know what to put on his forms.

    *rash around band-aids, blisters around mouth after dental work.

  45. nybgrus says:

    Michelle: it sounds like your boy may be having what colloquially called a “traction allergy.” The latex is not causing the problem, nor the adhesive. Instead it is the physical traction on the skin caused by the bandaid pulling or the dentist’s hand (or whatever device holding it open) that can cause these issues. This is not to say he may not be have (or develop) a latex allergy – but it is something to look into and possibly assuage some fear.

  46. nybgrus – “traction allergy” thanks so much for the information. That may be useful in the future. I will look into it.

  47. Roadstergal says:

    Since then my step-mother decided that if my dad had the allergy, the rest of us kids did to. So she never let us have penicillin. I don’t know what I took later that year when I had pneumonia, but it was not penicillin.

    My dad is profoundly allergic to penicillin – full-blown anaphylactic attack, collapsed and couldn’t breathe. I don’t have the tiniest reaction (other than the killing-bacteria thing). You might try a test.

    (What’s funny is that they gave me sulfa for some random bacterial infection when I was young, with the just-to-be-safe reasoning your stepmom used, and I had a milder but still substantial anaphylactic reaction to sulfa.)

  48. Nikola says:

    @Harriet Hall:
    Thanks for the aspartame study and clarification:)

  49. tuck says:

    Just got back from the allergist. The first two skin tests: no reaction to penicillin. We’re doing an in-office challenge test in a few weeks, which will fully clear me, but there wasn’t a hint of a reaction this morning.

    I’ve also had reactions to sulfa drugs and amoxicillin, and he said they don’t have good tests for those, unfortunately.

    But it’s nice to be able to cross one allergy off the list.

    So Thanks!

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