Allergy tests

Definition
Allergy tests indicate a person's allergic sensitivity to commonly encountered environmental substances.

Purpose
Allergy is a reaction of the immune system. Normally, the immune system responds to foreign microorganisms and particles, like pollen or dust, by producing specific proteins called antibodies that are capable of binding to identifying molecules, or antigens, on the foreign organisms. This reaction between antibody and antigen sets off a series of reactions designed to protect the body from infection. Sometimes, this same series of reactions is triggered by harmless, everyday substances. This is the condition known as allergy, and the offending substance is called an allergen. Common inhaled allergens include pollen, dust, and insect parts from tiny house mites. Common food allergens include nuts, fish, and milk.
Allergic reactions involve a special set of cells in the immune system known as mast cells. Mast cells serve as guards in the tissues where the body meets the outside world: the skin, the mucous membranes of the eyes and other areas, and the linings of the respiratory and digestive systems. Mast cells display a special type of antibody, called immunoglobulin type E (IgE), on their surface. Inside, mast cells store reactive chemicals in small packets, called granules. When the antibodies encounter allergens, they trigger the release of granules, which spill out their chemicals onto neighboring cells, including blood vessels and nerve cells. One of these chemicals, histamine, binds to the surfaces of these other cells, through special proteins called histamine receptors. Interaction of histamine with receptors on blood vessels causes neighboring cells to become leaky, leading to the fluid collection, swelling, and increased redness characteristic of a runny nose and red, irritated eyes. Histamine also stimulates pain receptors, causing the itchy, scratchy nose, eyes, and throat common in allergic rhinitis.
The particular allergens to which a person is sensitive can be determined through allergy testing. Allergy tests may be performed on the skin or using blood serum in a test tube. During skin tests, potential allergens are placed on the skin and the reaction is observed. In radio-allergosorbent allergy testing (RAST), a patient's blood serum is combined with allergen in a test tube to determine if serum antibodies react with the allergen. Provocation testing involves direct exposure to a likely allergen, either through inhalation or ingestion. Positive reactions from any of these tests may be used to narrow the candidates for the actual allergen causing the allergy.
Identification of the allergenic substance may allow the patient to avoid the substance and reduce allergic reactions. In addition, allergy testing may be done in those with asthma that is difficult to manage, eczema, or skin rashes to determine if an allergy is causing the condition or making it worse. Allergy tests may also be done before allergen desensitization to ensure the safety of more extensive exposure.
Skin testing is the most common type of allergy test. There are two forms: percutaneous and intradermal. In percutaneous or prick testing, allergen solutions are placed on the skin, and the skin is then pricked with a needle, allowing the allergen to enter the skin and become exposed to mast cells. Scratch testing, in which the skin is scratched instead of punctured, is used less often. Intradermal testing involves directly injecting allergen solutions into the skin. In both tests, a reddened, swollen spot develops at the injection site for each substance to which the person is sensitive. Skin reactivity is seen for allergens regardless of whether they usually affect the skin. In other words, airborne and food allergens cause skin reactions equally well.

The range of allergens used for testing is chosen to reflect possible sources in the environment and may include the following:
pollen from a variety of trees, common grasses, and weeds
mold and fungus spores
house dust
house mites
animal skin cells (dander) and saliva
food extracts
antibiotics
insect venoms
Radio-allergosorbent testing (RAST) is a laboratory test performed when a person may be too sensitive to risk skin testing or when medications or skin conditions prevent it.
Provocation testing is done to positively identify suspected allergens after preliminary skin testing. A purified preparation of the allergen is inhaled or ingested in increasing concentrations to determine if it will provoke a response. In 2004, scientists introduced an optical method to continuously measure the changes in nasal mucosa (lining) changes with an infrared light to help improve the accuracy of provocation testing. Food testing is much more tedious than inhalation testing, since full passage through the digestive system may take a day or more.

Precautions
While allergy tests are quite safe for most people, the possibility of a condition known as anaphylaxis exists. Anaphylaxis is a potentially dangerous condition that can result in difficulty breathing and a sharp drop in blood pressure. People with a known history of anaphylaxis should inform the testing clinician. Skin tests should never include a substance known to cause anaphylaxis in the person being tested.
Provocation tests may cause an allergic reaction. Therefore, treatment medications should be available following the tests, to be administered, if needed.

Description
In prick testing, a drop of each allergen to be tested is placed on the skin, usually on the forearm or the back. A typical battery of tests may involve two dozen allergen drops, including a drop of saline solution that should not provoke a reaction (negative control) and a drop of histamine that should provoke a reaction (positive control). A small needle is inserted through the drop, and used to prick the skin below. A new needle is used for each prick. The sites are examined over the next 20 minutes for evidence of swelling and redness, indicating a positive reaction. In some instances, a tracing of the set of reactions may be made by placing paper over the tested area. Similarly, in intradermal testing, separate injections are made for each allergen tested. Observations are made over the next 20 minutes.
In RAST testing, a blood sample is taken for use in the laboratory, where the antibody- containing serum is separated from the blood cells. The serum is then exposed to allergens bound to a solid medium. If a person has antibodies to a particular allergen, those antibodies will bind to the solid medium and remain behind after a rinse. Location of allergen-antibody combinations is done by adding antibody-reactive antibodies, so called anti-antibodies, that are chemically linked with a radioactive dye. By locating radioactive spots on the solid medium, the reactive allergens are discovered.
Provocation testing may be performed to identify airborne or food allergens. Inhalation testing is performed only after a patient's lung capacity and response to the medium used to dilute the allergen has been determined. Once this has been determined, the patient inhales increasingly concentrated samples of a particular allergen, followed each time by measurement of the exhalation capacity. Only one allergen is tested per day. Testing for food allergies is usually done by removing the suspect food from the diet for two weeks, followed by eating a single portion of the suspect food and follow-up monitoring.

Preparation
Skin testing is preceded by a brief examination of the skin. The patient should refrain from using anti-allergy drugs for at least 48 hours before testing. Prior to inhalation testing, patients with asthma who can tolerate it may be asked to stop any asthma medications. Testing for food allergies requires the person to avoid all suspect food for at least two weeks before testing.

Aftercare
Skin testing does not usually require any aftercare. A generalized redness and swelling may occur in the test area, but it will usually resolve within a day or two.
Inhalation tests may cause delayed asthma attacks, even if the antigen administered in the test initially produced no response. Severe initial reactions may justify close professional observation for at least 12 hours after testing.

Risks
Intradermal testing may inadvertently result in the injection of the allergen into the circulation, with an increased risk of adverse reactions. Inhalation tests may provoke an asthma attack. Exposure to new or unsuspected allergens in any test carries the risk of anaphylaxis. Because patients are monitored following allergy testing, an anaphylactic reaction is usually recognized and treated promptly. Occasionally, a delayed anaphylactic response can occur that will require immediate care. Proper patient education regarding how to recognize anaphylaxis is vital.

Normal results
Lack of redness or swelling on a skin test indicates no allergic response. In an inhalation test, the exhalation capacity should remain unchanged. In a food challenge, no symptoms should occur.

Abnormal results
Presence of redness or swelling, especially over 5 mm (1/4 inch) in diameter, indicates an allergic response. This does not mean the substance actually causes the patient's symptoms, however, since he or she may have no regular exposure to the allergen. In fact, the actual allergen may not have been included in the test array.
Following allergen inhalation, reduction in exhalation capacity of more than 20%, and for at least 10-20 minutes, indicates a positive reaction to the allergen.
Gastrointestinal symptoms within 24 hours following the ingestion of a suspected food allergen indicates a positive response.
Key Terms
Allergen
A substance that provokes an allergic response.
Anaphylaxis
Increased sensitivity caused by previous exposure to an allergen that can result in blood vessel dilation (swelling) and smooth muscle contraction. Anaphylaxis can result in sharp blood pressure drops and difficulty breathing.
Antibody
A specific protein produced by the immune system in response to a specific foreign protein or particle called an antigen.
Antigen
A foreign protein to which the body reacts by making antibodies.
Histamine
A chemical released by mast cells that activates pain receptors and causes cells to become leaky.
Mast cells
A type of immune system cell that is found in the lining of the nasal passages and eyelids, displays a type of antibody called immunoglobulin type E (IgE) on its cell surface, and participates in the allergic response by releasing histamine from intracellular granules.

For Your Information
Resources/Periodicals
Hampel, U., et al. "Optical Measurements of Nasal Swellings." IEEE Transactions on Biomedical Engineering (September 2004): 1673-1680.

Credits

Gale Encyclopedia of Medicine, Published December, 2002 by the Gale Group The Essay Author is Richard Robinson.