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ASo for the past week I also. Because the milk stout and like. I don't know, I just have a. I had a suspicion that I feel like it has to do with milk or like the whey protein I was having. I stopped doing that for the. For the last four or five days.
BSo you went off milk?
AYeah, I went off milk and it felt better and. And then these results came in indicating no milk and I had like a little bit of milk again. And that's when the symptoms started again.
BAnd the symptoms of the hives?
AYeah, it's more like the. The hives. Oh, I forgot to mention that I've. Since the omeprazole I stopped. We suspected that's the only new thing I was having right then the omeprazole caused the allergy so I stopped having the omeprazole and the doctor instead prescribed Pepcid to me, which I've been having one a day since that day to manage my acidity.
BI'm sorry, you're off the omeprazone? What do you want?
AA Pepcid 20 milligrams a day.
BAnd you're fine with the pep said?
AYeah, I've been having that like once a day every day since May. May 20.
B20.
AYou can obviously send this digitally to you as well.
BHi there. How are you? Hey. This happened once before.
AI had left though by the time.
BThis happened and so I think I like got an extra. What. Sorry about that. Okay, what is. I don't know what. Try. I don't know what this is. Let's try a 14. Okay. Some wheat. Weird. Okay. Okay. So now do you have issues with eating any of these foods?
ANot really. I like, not directly. I don't get like any over symptoms right off the bat if I eat any of these.
BSo.
AYeah.
BYou have peanuts, you have tree nuts and eggs and you're fine.
AYeah, usually I don't really get any acute symptoms.
BI mean milk is really not that positive. Okay. Yeah, we'll go scan this in cuz I want to have that.
AI can send it to you as.
BWell if you need it.
AYeah.
BAnd also this, the EGD2. And this was done I think May20. They didn't rescope you, right?
ANope.
BAre they going to do it or.
ANo, I. I didn't follow up after this.
BI mean, Yeah, I mean it's borderline for E, but it doesn't have. I don't think it has. I mean there's some, some specifics. The way the EOS and the esophageal esophageal esophagus looks with EoE, it doesn't really have those. You don't have furrows, you don't have the rings, have plaques. So this is probably as more just bad reflux. And usually the reflux meds get rid of it and would lower that, but you really need to be rescoped again.
AOkay.
BI would give you. There's a good guy at Cornell who specializes in, like, eosinophilic GI disease. I'd probably send you there because, I mean, if it is an eoe, then it has to be managed a little differently.
AYeah.
BAnd it generally is related to a food allergy. That's if it is essential to focus objects. But I'm not sure sure this shows that.
AI see.
BBut it's good to follow up and make sure because if it is an eoe, then you know, and you're on reflux meds. You're on prep it, Right. Pep, pepid, pepc. And the question is, do you need to be on that? Do you need. You know, it depends on how the. And the symptoms for reflux are better now.
AI mean, they're manageable. Like, once a day I take them and I'm fine.
BAnd the hives started. You had hives with the omeprazole, but then you also had hives without the omeprazole. So clearly it probably wasn't the omeprazole. Right. Maybe just been triggered by other things going on. But you had highs. Right.
AThere are a couple of foods that I do directly react to, but they're not hives. So, like, if I eat a banana or if I eat. Carrots. Bananas.
BBanana or what else?
ACarrots.
BCarrots. Oh, you get itchy mouth or something.
AI get coughing. Like, I cough for, like, 30 minutes straight. Yeah.
BWhen they're like, raw.
AYeah, raw banana or carrots sometimes happens with the wine as well, but yeah. These three are, like. I know. These three are trigger foods.
BThose are. The other ones are fine. Have you had raw. Because the raw nuts. Let's say almonds. How about raw almonds? Have you had raw almonds ever?
AYeah.
BDid you get itchy mouth or coughing or anything with that? No, no, peanut. Rh9.9 is. I have, like, one of the systemic ones. Hold on, RH9. There are some that are related to pollen allergy. Peanut. Yeah. So RH9 is that. But you've been fine with that.
AI looked at all the proteins that were showing up high, and they belong to, like, a class called lipid transfer proteins. I Also read somewhere like, sometimes you need a co factor for, like the allergy to actually show up. Maybe the alcohol that I had that day.
BRight. Makes it worse. Right. Makes it worse. Because, I mean, clearly if you're not reacting to these foods, I don't want you to stop. That's why it's important to know if you do have eoe. Because if you do have eoe, maybe some of these foods are contributing to it because you don't have a. It's not a clear food allergy. You wouldn't know except you'd have buildup of these cinnamon pills in the esophagus. It's not like you're immediately going to have symptoms usually. So, I mean, some people do, but it's usually rare. So these could be more significant to me. Oe. But if you're eating them, I mean, nlty all of a sudden, after we could have hives to all these foods.
ASo you don't think that there's a possibility that both these things are connected?
BLike, I mean, while the hives. So you had hives. So you have reflux. You have these food things. I don't know what to make of it. And then you have hives. Correct. Those are the three issues. And the hives now that you had three weeks ago, you had the hives and you've had them. Well, you said they're better.
AThey're better.
BHave, like red patches.
APatches sometimes, yeah.
BThree weeks. But you had steroids. Are you still taking antihistamines now?
AYes. When the red patches show up.
BStill on. So you take. Still take antihistamines as needed.
AYep.
BHow often is that?
AIt really varies, but, like, it's usually one Zyrtec and one Allegra the day I see the red patches.
BYou take a Zyrtec and Allegra at the same time?
ANo, no, no. 1. One during the day and the Zyrtec at night. They show up, like, I don't know, once every three days still.
BAbout every three days. Yeah.
ABut it did really table down.
BSo you take 11 in the mornings or take a night when you have those red patches, and then you can go another few days and it comes back again.
AYeah.
BAnd they did buy. Let's see. H. Pylori can cause highs and cause reflux and cause highs. But they said it was next, so. But this was a while ago.
AYeah, this is quite some time ago. Yes, before my first hive episode.
BThis is almost two years ago. Right. Since 6. 23. We're in March. March 25th. So almost just two years ago. I would do blood work, not the food stuff. I would do blood work for sort of a chronic hive workup. Cuz you had eyes before they came back again that sort of a, sort of a chronic on a pattern and see if there's anything that's triggering it. I mean in terms of food allergy, if it was only a food allergy, it only happened when you have the food, not when you didn't. You said milk seems to trigger it. Although milk allergen was not high. But have you had it without having milk? What exactly have you had the hives without having milk?
AI mean I have milk in my everyday diet every day.
BBut you don't have hives every day. Right. So that's probably not it. I mean if you told me you broke on highs when you had peanut, then okay, it's related to peanut. But if you sort of had weeks of highs after having a peanut, that's not going to happen.
AExactly.
BUnless you have peanuts every day and perpetuate the allergy. Yeah, I just don't know how much of these are important or not. That's probably more reflux ui, but probably not the hives. The hives you would know because when you eat the food you'd have the reaction. I mean alcohol could definitely trigger hives underlying hives that you have. It's not the only reason, but it can trigger it. So with people who have hives, I sort of tell you be careful with alcohol, you'll have to get worse. You can drink if you want to, but your hives will get worse. So. And how long ago was this was the steroids that you took at the same time?
AThey started about three weeks ago.
BThree weeks ago. Okay, so you've been on for a while. Yeah, yeah. Because it can affect blood work. So I would do blood work versus my chronic hive workup and see if there's anything that jumps out.
AIs this regular blood work? Because I have a report from like.
BWell there's specific like thyroid antibodies, there's an antibody that causes hives like Tryptase ige. So okay, probably not. I mean that, I mean I don't need to do. Did you have, what did you have? Do you have a cbc, chemistry, those things? I don't need to repeat again.
AIt was like a general blood work. What was that four weeks ago or five weeks ago? Not very long ago.
BYeah, if you have the results showing me that I don't need to repeat those if they're caused, if they're normal, they're pretty Much normals on that.
AThe eosinophils are dead. Are fine.
BThey're fine.
AYeah.
BThat was a few weeks ago.
AYeah. Okay.
BSome people with EOE will have peripherally symphilia, but not everyone.
ADo you want me to send it to you?
BYeah, if you can at it's info Hudson allergy dot com. All one word Hudson Allergy one word dot com. And if you can send also any of these things you have would be great because we'll have upload them info.
AHudson allergy dot com.
BYeah, Do you have. Do you have a copy of the. This report? These labs would be great. So take them back. I do a lot of compliments. The sesame compliment I did, the wheat compliments a lot. I'm gonna do all that. This was the general doctor who did it. Yeah.
AYeah.
BDo you take any other medications right now?
AOh, no.
BSo you're on Pepcid, right? Pep here on Olagran Z. Right. And anything else you're taking? I wouldn't really say if. Anol allergy. I wouldn't call that an ep. Yes. If it only happened with. It's not a very common allergen and it can be allergic to anything. But not the pilot on the list. Yeah. Any allergies, any drugs that you know of ever react to anything?
ANo. Yeah, like I said, like first time hypertensions occurred in my life.
BHow about environmental? Anything new in the environment? Do you have any pets that are new? Are you living in a new place?
ANot really. Nothing's changed. I looked at all my detergents, bath soaps, shampoos. Nothing. Nothing really has changed.
BWhat else? Anyone in the family have allergies or hives or anything or anyone with reflux or any allergic diseases?
ANo, not really. Like, I come from India and like allergic. This stuff is like. So.
BOkay, and right now do you have any. Any red. Those red patches or anything? When's the last time you took. When's the last time you took your lig?
AI took another because I had some symptoms last night.
BOkay. And do you have a picture of what those are that are not really fine?
AYeah, you can't really see them in the picture because, I don't know, the camera modifies like the skin tone a little bit. But let me. I don't know if you can really make them out, but they're little. You see the redness over here?
BBut they're not itchy.
AThey're not itchy, but I get this tingly sensation. And that's when I went to look. Yeah.
BAnd that's just since you've stopped since the highs went away.
AYeah.
BOkay. Yeah, we can definitely work that up. LabCorp is the lab you want me to order labs for or back.
ADid you get the documents?
BThey haven't uploaded them yet. They have to get them.
AOkay.
BOkay. You said there's a cbc. Do you have. Oh, you sent it to me. Okay, Chemistry. Otherwise you're being feeling well. Have you had a cold? Have you had. Do you feel sick at all?
ANo, my dog.
BYou feel fine?
AI feel fine. Yeah, you can have like look at.
BI just want to see what the cbc Ace and. Good. Yeah. Okay, that's good. So you've had. Since you've had the endoscopy two years ago, you've been on some medicine every day.
AYeah.
BAnd you have been symptomatic because when you stop it, you do have symptoms. Okay. Yeah, I should definitely CGI again because you need to be scoped again and see what's going on. Because again, if it is eoe, then we have to find a little more, you know, different management of it and then maybe those food allergens become more important. The most common trigger for EoE in adults is dairy. Again. But you wouldn't really know. You eat it and you're fine, but it's causing. But again, I'm not so sure it was EOE because I think the. The level was low to begin with. But I don't know because you're still symptomatic.
AYeah, I can probably get it done.
BSo I'm doing chronic urticaria. Pylori thaw, which is two years ago. Oh, here. It's in the chart already. Okay.
ADoes it make sense to get like a prick test done?
BI can't do that now. Cuz you're on antihistamines. You need to outfit for like probably five to seven days. I don't think so. For what you're coming to me with. Maybe if some of the foods were equivocal, but again, I'm not so sure. Environmental stuff. I mean, you said you don't have pets, correct?
AI really doubt it's dust either because I mean I visit home in India and that's pretty dusty like compared to.
BOkay, I'm gonna just sign this for you. I think that's it. Just my day head workout. Let me look at your. Because it kind of cuts everything off. Okay.
AThat's the general.
BIt. Okay.
AGreat.
BSo I think, I mean it's probably fine for you to take like an Allegra daily and then if you get the rash. Take a Zyrtec at night. Like I mean, I guess, I mean, it depends quality of life, what you want to do. I mean, you can wait and do it as needed or if it's pretty much happening every day, few days, just sort of take everything. I mean, it's up to you how uncomfortable you are with it because definitely you take up to four of any the 24 hour intestines in a day.
AOkay.
BOlequin Zyrtec are good options. I like them. You can take up to four of any of them a day.
AOkay.
BBut again, it depends how uncomfortable. You can just do a liquor every day and then add a Zyrtec if you need or another liquor if you need and see what's going on. Is it getting less frequent, less intense over time?
AIt did like until like food for the four days I was dairy free again, it might be placebo, I might be making it up.
BYou know, obviously if eating dairy causes problems, avoid dairy.
ABut yeah, just. I don't know, maybe it's like psychosomatic in some sense either. Like if I stress about it, it gets worse.
BWell, stress definitely can exacerbate stuff too. The dairy didn't affect the reflux though, as far as you know, did it? Does it make it worse?
AI don't know. I didn't, I didn't try like a long term, six to eight week diet, which like I could try that.
BI mean in terms of the reflux, it's good to get your new baseline because I have no idea what your baseline is. If it's not UE anymore, you don't necessarily have to stop the dairy. If it looks like it is UE and your eoscending pills are still high, then it's probably worth doing dairy avoidance and you know, over time and see how you do.
AOkay.
BAnd your issues were more burning. It wasn't like food impaction or anything.
AIt wasn't actually.
BIt was like that trouble swallowing. It was really just burning. It's traditional. That's more typical of reflux. Presenting as an adult is usually like food impaction, difficulty swallowing.
AYeah.
BBut yeah, you could go off dairy and see. I mean I would guess I would keep the anti as you are when take more frequently and then go off dairy because then you don't know what, which one improved it. You can just stop the anti altogether. Stop dairy and then see if it's better. And then if you still have hives off the dairy, then that's not related to the dairy. Yeah, so. And when you scratch Your skin. Do you get hives or anything? And the only other. There's little red. Those red things on your legs or is it all over?
AThe first place they appear is on my legs. The second place they appear on your arms.
BAnd no more swelling.
ANo more swelling. Swelling hasn't happened since the steroids.
BAnd that was a six day course of steroids a few weeks ago. Yeah. Okay, so that's my plan for you would be to get blood work done at LabCorp.
AWhat. What exactly are we looking for in this blood work?
BUsually chronic hives. I look for auto inflammatory. So thyroid antibodies can definitely trigger hives even if you have normal thyroid function. There's an antibody. There's a CU index, chronic urticari index, which also can be elevated if you have chronic hives. And it's just like an autoimmune component to it. And there's an antibody that triggers histamine release from mast cells and really doesn't do anything else.
AOkay.
BTryptase just overall trip days release from allergy cells during an allergic reaction. If you have a higher baseline Tryptase, you're more prone to having hives and allergic reactions. There's hereditary condition which sort of has an elevated trip taste and there's like. There's a more significant like mastocytosis which is a more malignant condition. Don't have elevated tryptase. Ana sort of an overall screening for autoimmunity just to see. It's not typical, but you have reflux, you have rashes. It's. This is one entity presenting with different systems. Or is it they're just not related.
AI see.
BI didn't do CBC again because your egos are fine. I didn't do chemistry because you're responding. Your LFCs are a little high before. I didn't repeat them. Your internist didn't seem too concerned. So it's more the autoimmune stuff. Auto inflammatory stuff. And if they're positive there's not much I can do about it. It's just that's your answer and generally means it's going to be a longer road. And we just treat the symptoms if you know. But it's good to sort of know so you're not racking your brain. What a moment.
AThat would definitely give me some peace.
BYeah. And I think the reflux stuff you have to work out and see if that truly is E or not.
ASo the blood test is essentially to figure out if this is chronic or not.
BYeah. Just to see if there's any inflammatory Component going on causing this to be chronic. The food stuff. I didn't do any more food allergy testing because they did a bunch and you're positive to a bunch. I just don't. You don't seem to have symptoms, so I don't. I would sort of continue your diet the way it is. You can't consider holding up back on dairy.
AYeah, like the, what I read about UE was like the first line of treatment is like 6 food elimination diet. I could definitely give that a go.
BNo, I wouldn't do. I would just do for adults generally, especially if you have dairy regular D just do dairy.
AOkay.
BYou don't do. Yeah, I don't do all that.
AOkay.
BIt's just a hard diet to follow and you don't know what it is. And also I wouldn't, I mean I would get a baseline scope again.
AOkay.
BBecause it doesn't.
ABecause again yeah, we're not sure.
BYou're not sure if it's. If you still have it.
AI don't even have a symptom.
BAnd you know if you're doing that you may not need to. So it's not bad to get. This is your baseline and then go on a dairy free diet. You know, generally get resoped again again a couple months later and see if it's better.
AOkay. I'm just a little apprehensive about doing general anesthesia so many times. Is that like.
BWell, I mean it's generally safe. I mean, I mean they were, you know, they were teaching like honestly do you know, introduce like go on the food elimination, reintroduce the food every 16 weeks and get a scope every time. Yeah, I don't really know anyone who does that. Especially you know, GIs. It's hard to get them to scope all the time and no one wants to do it. But definitely doing it. You did it two years ago. And again I think it's definitely worth it because you do have still some symptoms and it's not clear that was EOE and just the management has to be better because if you're still symptomatic, you shouldn't be taking reflux meds every day for two years. True. So I would definitely at least get another scope and then decide how bad it is. If it is something that's bad, you may need to get scoped every few months. If it's not, then you just sort of see symptom wise if you have symptoms or not. So I would do it again just to reassess because you can't you know, diagnose you with a chronic condition and then not follow up. Unfortunately, there's no other way for me to tell. Just they go in there and look at it.
AYeah, yeah.
BBut you haven't had one in two years, so you're good. So I would do that. I'll. I'll recommend the guy at Cornell. He does EOS stuff. Okay. And yeah, because not every GI is good at treating it. There are, you know, it's sort of a fairly new thing for adults. There is injectable medicine, dupixent once a week for that. There's also like a swallowed steroid now that's been approved by the fda. So there is some new treatment for iwe that's new. So, okay, you do want to go to a GI who knows how to follow it, because otherwise may not know. And, you know, you want to make sure they look at it and say, this is not a week. This is not how it presents. So it is somewhat of specialized diagnosis these days. So get the blood work done, take the end of things as needed. Consider dairy free diet. Just more to see if it helps with the hives. It's up to you.
AYeah.
BDoesn't sound like it's only that because you have had hives and not had dairy. So I don't think so. But you know, I would do definitely not the full like 6, 8 food elimination diet. That's extreme.
AOkay.
BAnd it's. We have no basis to go by. And if, you know, hives end up going away, you're gonna say, oh, it was due to those foods, but it could have just been because they went away and then you're stuck. So I would limit the. Yeah, I mean, the restricted diets you, I'm not such a fan of unless they really need them.
AOkay.
BWe have to make sense of those other labs. I mean, so I don't love doing food allergy testing. If you don't have symptoms with foods because now you're positive things, I have no idea what to make of it. If you clearly don't have symptoms and you eat it, you're fine to have it. But then people are like, oh, I don't want to eat it. Or now they're like, oh, maybe I do have symptoms. But like even eating it, fine. So now it's like whole stuff into question. But if I test people who are walking around to take people off the street who eat foods all the time and test them and they're positive to things, doesn't mean anything. So anyway, so yeah, so the Antistamines is needed. I would do GI again. I get the lab work done and let's see.
AOkay.
BAnd sort of reassess these various conditions.
AAnd do I need to be not taking the anti SMS for the blood work?
BNo, you can take them. It's fine. It only affects skin testing.
AOkay.
BI don't think I need to skin test because you had the food stuff, which is not. I don't know what to make of it. And environmental again. I mean, springtime allergies don't do this. Potentially dust or PET could, but I don't have. You don't have pet? There's no reason to suspect you have an increased influx of dust. So I don't think that's it.
AYeah. My personal suspicion is I think both times that this suddenly occurred was when I think I had a beer in both cases. I do have beers regularly though. But I feel like it was a combination of like something I had and the beer that triggered it.
BThat triggered. Yeah, the alcohol can definitely do it. It just triggers the preservatives in it or something. It triggers the underlying condition and that people with chronic hives do. It's just stressful situations trigger it. Alcohol can trigger an infection, can definitely trigger it. Certain medications can. So, you know, you could be going along, fine, then have something that triggers it and then you can have it for another, you know, whether it's weeks or months or years, then it goes away again. Then some other trigger that's kind of the chronic. It's not necessarily every day for years. It can ebb and flow depending on what the triggers are.
AI see. Okay.
BBut it could have been that, you know, maybe it was stress or something else.
AMaybe it was stress.
BMaybe you had a mild virus and that was the only manifestation of it is hives and swelling. I've seen a lot of people lately with eyelid swelling and I think it's viral. It's weird. It's all they come in is eyelid swelling. They're not allergic to anything. So there's some virus causing eyelid swelling out there. I don't know what it is, but I've seen quite a bit of it. Okay. So, yeah, I mean, knowing alcohol will likely trigger the hives. Drink if you want to drink, but just with that caveat, you may wake up the next day with more hives or some swelling. Just take more anti histamines if you want to. Makes sense. Okay, so I'm going to email you all this stuff so you have it and sort of what my plan is you can pick up the lab form on the way out. The labs take a few days to come back. So when I get them back, I will send you a message or explain what it is. We'll see how your hives are doing and then we'll sort of see how you're doing. I mean, if the hives persist. Xolair is a great medicine. It's a once a month injection. It works super well for hives. If you do have eoe, dupixent is then almost. FDA is in the process of being FDA approved for hives. I don't think it works as well in solar, but it also is approved for iwe. So potentially if you had hives and iwi, dupixent is probably what I would do. Or maybe this stuff is going to go in its own. You don't do anything. So I don't know. I don't know how it's going to be. It seems like it's a little less intense, so that's good. The question is, is it going to come back again in a few months or what's going to happen? Because it came back again already. Okay, so lab work, look into gi. I'll send you the guy's name and we'll touch base and sort of take the anti sweets as needed and don't go crazy with your diet. But you can try probably dairy free and maybe minimize alcohol. The only thing I would think. Okay, but in terms of the reflux, we're not going to know if dairy made a difference, but we may know the hives go dairy free for a weekend of the high. I mean, I think if the highs are gone, I think it's gone anyway.
ABut I don't know.
BI don't know. Complicated. It's not so easy. Okay, so I'm gonna send you some information, some handouts. We'll touch base and labs are back and then we'll go from there.
AOkay, and you suggest I get gi, like another endoscopy done?
BI mean, I would talk to GI and see what they think. I mean, I. Most likely they'd want a rescope. If you're still symptomatic and that was your last scope a couple years ago, they probably want to rescope you just to see where you're at. Because I mean, if you're, if you had those symptoms and off meds, then probably is a moot point. But if you're still, if you're off the meds and get symptomatic, it's worth checking because if it is just reflux and it's not being treated. And get Barrett's esophagus if you get. If it goes untreated too long, and the. The, you know, the PPIs are stronger, and you may want to go back on a meprazole. Yeah. So I would. I would just tell. I mean, obviously, I would have an appointment with GI first to talk to them and see the airplane. Especially someone who knows eoe. They may say, yes, let's do it, or, no, let's wait and see, you know.
AOkay. Yeah, that sounds good.
BAnd so I'll email you all that, and then we'll see how it goes. Okay? Okay, sounds good. Okay. You can pick up the lab form on the way out.
AI think the doctors can go on in. Sorry.
BIt.
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