Clinical Allergy: Diagnosis and Management

Clinical Allergy: Diagnosis and Management is a volume from the Current Clinical Practice series (Springer). Series Editor Neil Skolnik correctly points out in his introduction that allergic disorders are among the most common seen by primary care physicians, that the science of allergy has greatly increased in scope over the past 2 decades, and that studies show that primary care physicians indicate a need for further allergy education.

To fulfill this educational need, author Gerald Volcheck indicates his goal to provide “clinically applicable information” to “unravel the mystery of allergy,” thus providing a “logical framework” for diagnosis and treatment. The primary audience for this work is described by the author as primary care physicians, medical students, residents, and junior allergy fellows.

The text begins with a review of immunology, emphasizing aspects relevant to allergic disease. The author accomplishes an exceptionally readable general overview of the humoral and cellular immune system and provides clear descriptions of the role of cytokines, chemokines, T regulatory cells, and mechanisms of immune tolerance. Much of this review chapter is not referenced in the subsequent clinical chapters. For example, the book does not address immunodeficiency or rheumatic disease, but the background enriches the reader's appreciation of subsequent chapters dealing with diagnosis and treatment.

The clinical chapters include discussion of environmental allergens, allergy testing, immunotherapy, allergic rhinitis and rhinosinusitis, allergic eye disease, asthma, urticaria and angioedema, atopic and contact dermatitis, drug allergy, food allergy, anaphylaxis, and insect sting allergy. Each chapter typically includes an overview of epidemiology and pathophysiology, clinical descriptions, differential diagnosis, approaches to the patient, and viable treatment regimens. A notable highlight is that each chapter closes with 3 to 5 clinical vignettes describing evaluations of pediatric and adult patients. The case studies bring the chapters to life by emphasizing the importance of a careful history, the appropriate selection and interpretation of diagnostic tests, and treatments including the importance of identifying and avoiding relevant allergens. Clinical pearls include lessons on common diagnostic pitfalls and disease masqueraders. For example, a stepwise evaluation of a 52-year-old man with a recent increase in symptoms of chronic rhinitis systematically excludes infectious and allergic triggers and eventually reveals rhinitis medicamentosa from an oxymetazoline nasal spray the patient originally did not report using because he did not consider it a medication. Another example involves a 26-year-old patient with recalcitrant asthma having numerous triggers and with nonadherence ruled out as contributing factors; careful attention to the symptom pattern of acute onset and possible stridor leads to a final diagnosis of vocal cord dysfunction.

The book is replete with helpful tables listing medications, diagnostic testing, and key aspects of diagnosis and treatment. Major diagnostic routines are summarized in figures, and color photographs are provided to illustrate allergic eye diseases and allergic skin rashes. A clinician would be apt to make photocopies of many of the tables and figures for handy daily use in the clinic. Each chapter concludes with a “Suggested Reading” section that typically includes expert review articles, practice papers, position statements, or key original research.

The text does not attempt to differentiate information that may be more relevant to allergy fellows than to primary care physicians. For example, the text includes details on skin testing, features of allergens, and how to prescribe immunotherapy, among other topics extraneous for most readers. Nevertheless, the structure makes it easy to go directly to a topic of interest by providing a detailed table of contents and extended numbering of sections and subsections. Accordingly, the reader can quickly locate summaries of practical advice for allergen avoidance without necessarily sifting through detailed descriptions of pollens, fungi, dust mites, and animal dander. Despite having details ready for the interested reader, the text remains primarily focused on providing practical clinical information, such as that emphasizing that allergy test results must be interpreted in the context of the medical history, because a positive result does not equate with disease.

A challenge for a single-author book is to maintain a high level of expertise, appropriately select areas of emphasis, and present current information over a broad range of topics. Success in these areas is evident in most chapters, in particular the chapter on asthma, which distills information from the 2007 National Asthma Education and Prevention Program Expert Panel Report to its essential and practical elements in a chapter that likewise reviews the salient aspects of asthma pathophysiology, diagnosis, and management. However, the literature review for the text appears to have concluded in 2007, because most of the suggested readings are from 2006 or earlier. Minor aspects are therefore dated; for example, a revised report on atopy prevention published in January 2008 is not included. Additionally, the author occasionally overstates or missteps, eg, stating that a supervised feeding of a possible food allergen is “contraindicated” in circumstances in which it may not be (if performed in experienced hands) or states that in vitro tests “are not performed properly in every laboratory,” when he probably meant, or should have emphasized, that different brands of the tests may have results not directly comparable with each other. When presenting likelihood ratios for diagnostic tests, the importance of pretest probability should have been reviewed. I also wish the book included a section on unproven methods of allergy diagnosis (eg, IgG testing, applied kinesiology) and alternative therapies (eg, herbal medicines).

However, these faults are minor compared with the book's success in presenting a comprehensive and accessible review of clinical allergy. In the end, Clinical Allergy: Diagnosis and Management meets its goals of providing clinically applicable information for primary care physicians and students. It serves as an excellent reference for reading about advanced topics within the fields of allergy and immunology.