Allergy differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Marufa Marium, M.B.B.S[2]

Overview

Allergy must be differentiated from other diseases that cause Dermatological (Urticaria, pruritus, flushing, Angioedema), Respiratory (Rhinorrhea,chest tightness,Wheezing, Dyspnoea, Sneezing, Shortness of breath) Mucosal (Mucosal swelling affecting nose, lips, tongue, larynx, pharynx, conjunctiva, GIT) Ocular (Periorbital edema, Conjunctival Congesion, Itching), Systemic (Hypotension). Allergy can be differentiated according to the type of allergy.

Differentiating allergy from other Diseases

Allergy must be differentiated from other diseases that cause Dermatological (Urticaria, pruritus, flushing, Angioedema), Respiratory (Rhinorrhea,chest tightness,Wheezing, Dyspnoea, Sneezing, Shortness of breath) Mucosal (Mucosal swelling affecting nose, lips, tongue, larynx, pharynx, conjunctiva, GIT) Ocular (Periorbital edema, Conjunctival Congesion, Itching), Systemic (Hypotension). Allergy can be differentiated according to the types of allergy.

Differentiating Allergy from other diseases on the basis of Dermatological, Respiratory, Mucosal, Ocular, Systemic Manifestations

On the basis Dermatological, Respiratory, Mucosal, Ocular, Systemic Manifestations, Allergy must be differentiated according to the types of allergy.

• Food Allergy is differentiated from enzyme deficiencies like lactose intolerance, fructose intolerance and malabsorption, Celiac Disease, Toxic reactions, Irritable bowel syndrome, Tyramine or caffeine toxicity.
• Allergic Rhinitis is differentiated from Acute Infectious rhinitis, Irritant rhinitis, Acute Rhinosinusitis, Hormonal Rhinitis, Vasomotor rhinitis, Gustatory Rhinitis.
• Drug Allergy can be differentiated under 2 headings, they are IgE mediated (Carcinoid Syndrome, Mastocytosis) and Non-IgE mediated (Kawasaki disease, Acute Viral or streptococcal infection, Acute graft-versus host disease, Hereditary angioedema).
• Asthma is differentiated from several respiratory diseases for example COPD, Allergic bronchopulmonary aspergillosis, Bronchiectasis, OSA, Chrug-strauss syndrome, Anxiety, Foreign Body in respiratory tract.
• Atopic Dermatitis can be differentiated from Seborrheic dermatitis, Psoriasis, Contact dermatitis, Psoriasis, Scabies, Nutrient deficiency ( Zinc, Vitamin B3, Vitamin B6), Hyper IgE syndrome, Wiskott-Aldrich syndrome, IPEX syndrome, Brutons Agammaglobulinemia.

Diseases		Clinical manifestations																	Para-clinical findings																	Gold standard	Additional findings
		Symptoms						Physical examination
														Lab Findings			Imaging							Histopathology
		Abdominal Pain	Diarrhea/ Nausea/Vomiting	Dysphagia/Chest Pain	Bloating/Flatulence	Regurgitation/Reflux	Urticaria/Angioedema / Mucosal Swelling/ Oral Ulcer	Dyspnea/ Rhinorrhea /Sneezing /Nasal congesion	Pruritus/Flushing/Conjunctival or OcularIrritation	Gastrointestinal	Dermatological	Respiratory	Mucosal	Ocular	Systemic and Other	Complete blood count and Complete metabolic panel	Specific Laboratory test	Hydrogen/Fructose breath Test, lactose intolerance test	Toxin or Others	Stool analysis Or Urine Analysis	Ultrasonography and Endoscopy	Colonoscopy, Sigmoidoscopy or Bronchoscopy	Barium Enema and X-ray		CT	MRI
Enzyme deficiencies and Malabsorption	+(Diffuse Mild abdominal pain)	+(Steatorrhea/Osmotic Diarrhea)	-	+	-	-	-	-	Abdominal distention, Mild tenderness -/+, Osmotic diarrhea Hepatomegaly -/+, Ascites -/+	Koilonychia, Edema, Dermatitis, Easy Bruisability, ecchymoses, Follicular Hyperkeratosis, Pale mucosa	Tachypnea -/+	Glossitis/Cheilosis/Stomatitis	Keratitis, Xeropthalmia, Night blindness,	weight loss, Failure to thrive, Fatigue , Generalized and muscle weakness, Arthralgia, Bone fracture, rickets/osteomalacia, Paresthesia, Ataxia	Iron deficiency anemia, Anemia of chronic disease, Increased ESR, Electrolyte imbalance, Serum Pr/globulin,	-	+ in lactose and fructose intolerance	-/ Autoantibodies(ANA in Connective tissue disease, Antimitochondrial Ab in PBC), CFTR mutation in CF, Immunoglobulins in Immunodeficiency, HIV-ELISA/Western blot in HIV, 5-HIA in Carcinoid, Gastrin in Zollinger Ellison syndrome, TSH in Dysfunctional thyroid gland	Stool analysis: Decreased pH, Increased Fecal Fat, Increased electrolyte, Increased osmotic gap, stool WBC, Calprotectin	USG rule out ascites, lymphadenopathy, hepatobiliiary disease, lymphangiectasia, gastrinoma, somatostatinoma	-	-	to rule out pancreatic cause of malabsorption, malignancy	-	Hydrogen breath test for Carbohydrate intolerance, Antimitochondrial Ab in PBC, CFTR mutation in CF, Immunoglobulins in Immunodeficiency, HIV-ELISA/Western blot in HIV, 5-HIA in Carcinoid, Gastrin in Zollinger Ellison syndrome	-
Inflammatory Bowel Disease	+(Right LQ pain in Crohn's Disease, Colicky abdominal or rectal pain in UC)	+ (Bloody diarrhea or Mucus or pus in stool)	-	+	-	+	-	-	Abdominal distention, RUQ or LLQ or rectal tenderness -/+, Bloody diarrhea Hepatomegaly -/+, Ascites -/+	Pyoderma gangrenosum, Erythema nodosum	-	Aphthous Stomatitis	Uveitis, Episcleritis, scleritis	Weight loss, Ankylosing spondylitis, Sacroiliitis, Arthralgia, Osteoporosis, Primary biliary cholangitis, Nephrolithiasis	Anemia of chronic disease, Increased ESR, Electrolyte imbalance, Serum Pr/globulin, Ferritin, CRP, Hypoalbuminemia,low B12	-	-	-	Saccharomyces cerevisiae Ab, P-ANCA	Stool culture is performed to rule out infectious cause	Small bowel thickening	Aphthous ulcer, erythematous GI mucosa, erosions, spontaneous bleeding, fistula or stricture	Aphthous ulcers, cobblestoning, Skip lesion present in CD, edematous friable mucosa , erosions, paleness, granular mucosa are shown in UC	Thickened small bowel, or fistula	To rule out complication of Inflammatory bowel disease	Endoscopy with Ilieocolonoscopy	-
Celiac Disease	+/-, cramping	+	-	+	+	Gingivitis/Stomatitis/Cheilosis	-	-	Tenderness, Loose watery Diarrhea, Nausea, Vomiting, enamel erosion, aphthous ulcer, hyposplenism, constipation, acid reflux	Dermatitis herpetiformis, acne, eczema, seborrheic dermatitis, brittle nails	Asthma, tachypnea, wheezing-/+	Gingivitis/Stomatitis/Cheilosis	-	Fatigue, weight loss, arthralgia, arthritis, muscle cramping, peripheral neuropathy, headche, dizziness, ataxia, menstrual abnormalities	IDA, Anemia of chronic disease, Increased ESR, Electrolyte imbalance, Serum Pr/globulin, Ferritin, CRP, Hypoalbuminemia, low vitamin B12, low vitamin D	+	-	DNA PCR, HLA Haplotypes, IgA or IgG deaminated gliadin peptide Ab						-	Refractory Celiac disease	IgA or IgG anti TTG, HLA-DQ2/DQ8
Toxic reactions
Irritable bowel syndrome
Tyramine or caffeine toxicity
Gustatory Rhinitis
Acute Infectious rhinitis
Irritant rhinitis
Acute Rhinosinusitis
Hormonal Rhinitis
Vasomotor rhinitis
IgE mediated (Carcinoid Syndrome, Mastocytosis)
Non-IgE mediated (Kawasaki disease, Acute Viral or streptococcal infection, Acute graft-versus host disease, Hereditary angioedema)
COPD																										Spirometry
Allergic bronchopulmonary aspergillosis
Bronchiectasis
OSA
Chrug-strauss syndrome
Anxiety
Foreign Body in respiratory tract
Seborrheic dermatitis
Psoriasis
Contact dermatitis
Scabies
Nutrient deficiency ( Zinc, Vitamin B3, Vitamin B6)
Hyper IgE syndrome
Wiskott-Aldrich syndrome
IPEX syndrome
Brutons Agammaglobulinemia

References

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