Brief Answer:
May not be allergy, need more details as well.

Detailed Answer:
Hello sir,

Thank you for the opportunity.

I went through your son's history and also the reports attached, and I would like to know more about him, as follows:

1. When did he have the first episode of arthritis? Since then how many episodes has he had?

2. Since when did he have urticaria? What is the frequency of urticaria? How long do the urticarial lesions last - less than 24 hours or more than 24 hours?

3. Did he have any problem/s during early age - infancy or initial 2-3 years?

4. Did he have fever at beginning of arthritis episodes? Or such episodes occur entirely without fever?

5. Did he have any infection prior to starting these episodes? Did he have any serious sickness? Any surgery? Any hospitalization?

6. What was the reason for allergy testing? There are a few foods and air-borne allergens showing positive result. I would like to know whether those food really cause troubles to your son.

7. Does your son have repeated nose symptoms (sneezing,running nose, nose congestion) or eye symptoms (redness or itching or excessive watering) or asthma-like symptoms?

8. since how long does your son have constipation? What are the symptoms? Does he have any other digestive complaints?

9. What is usual diet of your son? Does he take packed foods (containing preservatives, colors, flavoring agents, etc) frequently?

10. How has he responded to the treatment? i.e., naprosyn. Does it provide relief?

Above details would help me to know more about immunity of your son. At present, the reports do not favor allergy as cause of his arthritis and urticaria.

Please feel free to ask any other query on follow-up. Please feel free to add any other details (use of complementary medicines e.g Ayurveda and homeopathy, any possible triggers that you might be thinking, etc) on follow-up. It will be my humble pleasure to help you with the best of my knowledge and experience as an allergist.

Wish your son a very good recovery and the best of the health.

Thank you very much & regards,

Dr Parin N Parmar
Pediatric Allergy-Immunology Consultant

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Brief Answer:
Non allergic urticaria

Detailed Answer:
Dear sir,

Thank you for your detailed reply.

I went through your provided details and considering the series of events. Let me tell you that all the reports when considered together, they do not point towards any particular diagnosis. However, I am seeing a lot of positive points. I would like to make suggestions for your son as follows:

1. Let me start with "allergy" as it is the field of my expertise. At present, I would not "stamp"your son as "allergic". Serum total IgE (a good screening test for allergy) levels are below 200 in two reports (one separate report and the other in allergy testing report). This is not favoring presence of "significant allergy".

Moreover, he has had problems due to citrous fruits but not due to almonds, banana, wheat, chana dal. The "allergy levels" of these foods are also less than 3, which is not suggestive of allergy.

Please remember that allergy testing shows only possibility of allergy (in medical language - "sensitization" and not allergy. So please do not stop these foods unless they are causing symptoms to your son.

I usually suggest my such patients having dilemma regarding allergy more specific testing with Immunocap or allergy skin testing to confirm or rule out allergy.

This is first positive I am seeing - your son may not be allergic.

2. It is a common misbelief that urticaria are always due to allergy. Going through your son's history, his urticaria are triggered by sweating and citrous fruits. So I would first think of "benign urticarias" such as cholinergic urticaria. Those who develop itching to citrous fruits are more likely to have digestive disturbances rather than true allergies. Correction of constipation and improving digestion could cause improvement in such urticaria.

Also, his urticaria last for less than 24 hours, ESR is normal, total blood count is also normal - this further suggests non-rheumatic and rather benign nature of urticaria.

So this is second positive - your son's urticaria may not be allergic as well as non rheumatic; I would first think of "benign" urticarias.

For urticaria I would suggest you to treat his constipation first by ensuring plenty of fluids during the day. As he is taking plenty of fruits and vegetables during the day, I assume he is already having high fiber diet. Fibers without adequate water could be cause of constipation.

I usually suggest my such patients to have a warm milk with turmeric before going to bed, a simple practice based on Ayurveda to improve digestion and immunity. I also suggest my such patients to avoid "Virudha Aahar" (inappropriate food combinations) as per Ayurveda. You can consult an Ayurvedic practitioner to know more about this.

3. The first episode of arthritis had fever, but other episodes did not have significant fever or joint swelling. It means it could be consequences of the first event and not repeating episodes of actual arthritis.

This is the third positive - he might not be actually having repeated arthritis; he might have only arthralgia (Joint pain without swelling). His whole rheumatology investigations are also negative.

4. I would like to know more about his ophthalmological findings - what was the picture within eyes. If eye examination was normal, I would not think the spherical numbers have relation to arthritis.

As he has good response to naprosyn, I would suggest you to use analgesics when he has joint pain. If he has only pain and not swelling, I usually suggest paracetamol - a mild analgesic. (other analgesics could worsen urticaria)

5. Were I treating your son, I would add vitamin D supplementation to his treatment - this improves improves both immunity and urticaria.

6. I usually suggest my patients to avoid all the possible outside packed foods (with unknown preservatives, colors, flavors, etc) till their health become optimum. This is because food additives can cause many unidentified problems.

You have mentioned disappearance of some symptoms and appearance of new symptoms with homeopathic treatment. Please discuss this with your homeopathic doctor.

Hope above information and suggestions will be helpful to you. Although I cannot think of a particular diagnosis (such conditions in allopahty are known as "idiopathic"), I am seeing many positives in your son's clinical features. Please discuss these with your pediatrician.

Should you have any further query, please feel free to ask on follow-up.

Wish your son the best of the health ahead.

Thank you very much & regards,

Dr Parin N Parmar
Pediatric Allergy-Immunology Consultant

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