Table 1 –

Clinical pearls for diagnosis and management of patients with AGS

Consistently Inconsistent	Whether a reaction occurs to an individual exposure is inconsistent and often appears to follow no identifiable pattern for patients. The lack of consistent reactions is, in itself, almost a diagnostic hallmark. Over time, patients may experience a "progression" to more consistent reactivity and this likely reflects a new tick bite.
Isolated Gastrointestinal	Reactions can be GI only. Many patients carried a diagnosis of chronic diarrhea, IBS or GI food allergy syndrome prior to AGS diagnosis. Overwhelmingly, their symptoms are resolved following diagnosis; oral cromolyn solution can be useful in those patients with lingering GI symptoms.
Co-factor Dependence	Activity, alcohol consumption, and exercise can have profound influence on reactivity. Some patients appear to have reactions that require co-factors such that they can tolerate exposures in isolation; consistent with a diagnosis of co-factor dependent-AGS
Bedtime Routines	Many episodes occur after 10pm, some even later in the night Do not underestimate how many patients take diphenhydramine nightly for sleep and could be influencing the reactions in both occurance and severity.