There are some things that positively don't go together.  High risk.  Just plain dangerous.  You know, like a match thrown into an open can of gasoline...or trying to sell Barry Manilow CD's at a heavy metal rock concert...or

Injury in the allergically-prone patient. 

In my last entry, I mentioned we were going to try to look at the multiply-food-sensitized patient with multiple target-organ injury.  A taboo subject for most allergists.  And I showed a basic template of how a patient can become multiply-sensitized to foods.  Many times, traumatic injury can lead to this development.  Check out the diagram below:

Injury on an allergically prone patient can damage a patient in 3 ways.  I have numbered 3 arrows to focus attention on.  The arrow marked #1 indicates that a serious traumatic injury puts stress on the general immune system, and can actually be associated with accelerated development of overt allergic symptoms.  Hard to believe?  I've taken enough histories over nearly 3 decades on allergic patients to see a definite relationship there, and I don't need a fancy term like "psychoneuroimmunology" to prove it.  Just ask enough patients over enough time whether there was a major traumatic incident immediately before the development of their initial allergic manifestations and I think you'll be impressed.  It doesn't even have to necessarily be a physical trauma, since I've seen serious emotional trauma be associated with the onset of overt allergic disease.  Like the woman who saw both of her sons killed in an accident, and then shortly thereafter developed asthma.  Or the person who developed the onset of their chronic hives while attending a funeral.  And had hives for years afterwards and sought my consultation...But physical trauma can be particularly devastating for the allergic patient, because often excessive NSAID's are used.

Focus on arrow #2.  As excessive NSAID's are used, a heightened intestinal permeability can develop.  There are numerous research citations relating NSAID-induced small bowel enteropathy and heightened intestinal permeability--and this spells disaster for the patient prone to developing food sensitivities.  Take the case of the pollen-allergic patient who saw me in the clinic because of the recent development of multiple food sensitivities.  It first developed during his usual pollen season--but with a twist.  As the story unfolded, he related that this pollen season was no different than any other--except that he suffered a sprain during it and took high doses of NSAID's--and shortly thereafter his multiple food reactions developed...Or the patient who had a history of pollen allergy, controlled on antihistamines, who was admitted to the hospital for NSAID-induced UGI bleeding--when the NG tube was pulled and he began eating once again, he developed multiple food reactions.  In both of these patients, they had stressors of pain, followed by high dose NSAID use.  And they both had a prior history of relatively minor respiratory allergies.

Finally, look at arrow #3.  One of the common phenomenons you'll see in someone who has suffered trauma to a specific part of their body is that area now has been "recruited" into the body's target organ allergic response.  That is, the part of the body that had been previously sprained, broken, stretched, crushed, etc. can now flare up with allergic reactions.  Sound strange?  Haven't seen it?  Then you haven't been looking.  Even sites of prior surgery can flare with new-onset allergic reactions.  Areas of prior inflammation/damage have a "memory" that makes them sources of reaction to other allergens.  This is a variation of the "fixed drug eruption" phenomenon we have all seen.  One patient I saw had seasonal respiratory allergies--he could handle the respiratory symptoms, but he had intense aching in the knee he had previously injured while playing football.  The orthopaedist said he had old degenerative disease, but the patient alertly noted the knee would only bother him DURING his allergy season, when his respiratory symptoms flared.  Another example:  the patient who eats an allergen (corn) and develops aching in a previously damaged site in his foot with running during the allergy season. 

The clinical pearl from all this?:  the allergic patient on hi-dose NSAID's is an accident waiting to happen.  Either reduce the NSAID's if possible, or at least have the patient avoid eating heavy, repetitive amounts of potentially highly allergic foods--diversification of the diet, and reducing milk, wheat, corn, yeast, and soy while on heavy NSAID's would be extremely prudent. 

Later, dude.