Achoo Syndrome

Clinical Features

Collie et al. (1978) described a 'disorder' characterized by nearly uncontrollable paroxysms of sneezing provoked in a reflex fashion by the sudden exposure of a dark-adapted subject to intensely bright light, usually sunlight. The number of successive sneezes was usually 2 or 3, but could be as many as 43. The 4 authors were the probands of the 4 families they reported. Several instances of male-to-male transmission were noted. 'Photic sneeze reflex' was suggested as the appropriate designation by Everett (1964), who found it in 23% of Johns Hopkins medical students. Lewkonia (1969) described sneezing as a complication of slit lamp examination.

Sneezing in response to bright light was said by Peroutka and Peroutka (1984) to be a common yet poorly understood phenomenon. In a poll of 25 neurologists at Johns Hopkins, Peroutka and Peroutka (1984) found the phenomenon in 9, but only 2 of the respondents knew that such a specific reflex existed. The Peroutkas (father and daughter) reported the reflex in 3 generations of their family: grandfather, the father (the proband), his brother and his daughter. The index subject (S.J.P.) invariably sneezed twice when he moved from indoors into bright sunlight.

Katz et al. (1990) found light-induced sneezing in 5 of 19 patients with nephropathic cystinosis (219800). This was presumably related to the crystal deposition in the cornea.

Lerner (1991) took Hunter (1990) to task for referring to the photic sneeze reflex as a 'comic syndrome.' He cited reports by Beckman and Nordenson (1983), Forrester (1985), Morris (1987), and Lang and Howland (1987), in addition to those already cited here.

Benbow (1991) reported that he had suffered from photic sneezing for over 20 years and having just learned of its existence found that the 'symptoms are more easily tolerated if you can put a name to them, even if that produces only an illusory understanding of their significance.' He commented on the potential hazards of photic sneezing if it occurs while one is driving a car on a sunny day. He said that he found that 'sudden exposure to sunlight when emerging from a road tunnel of sufficient length is sure to induce a sneeze.' Furthermore, 'driving through sunlit gaps in otherwise dense forest or past blocks of buildings can bring on a sneeze.'

History

Duncan (1995) pointed out public awareness of the ACHOO syndrome is much more widespread than one might guess, to the point that it has entered into the popular wisdom conveyed to preschoolers. In a best-selling children's book by Berenstain and Berenstain (1981), Papa and Mama Bear are taking Sister Bear and Brother Bear to their pediatrician, Dr. Grizzly, for a check-up. The cubs are expressing their apprehension about the possibility of injections when Papa Bear suddenly cuts loose with an explosive sneeze. 'Bless you!' said Mama.' 'It's just this bright sunlight,' sniffed Papa. 'I never get sick.'

Lehvaslaiho (2003) found an early reference to the ACHOO syndrome by Aristotle (Barnes, 1984). In Book XXXIII, in a section entitled 'Problems concerning the nose,' Aristotle stated: 'Why is it that one sneezes more after one has looked at the sun? Is it because the sun engenders heat and so causes movement, just as does tickling the nose with a feather? For both have the same effect; by setting up movement they cause heat and create breath more quickly from the moisture; and it is the escape of this breath which causes sneezing.'