Shhhhh...we're quietly discussing a taboo subject, so I want to keep this quiet.  Over the last several journal entries, I've focused on how "simple" allergy patients become "complex" allergy patients with multiple food sensitivities involving multiple target organ involvement.  This is an important subject, because we see these patients not infrequently in our allergy practices.  And what I'm going to say next will probably put you at risk for a dangerous elevation of your blood pressure, or even a seizure, so be forewarned--I've inserted another notorious black box warning for your protection, so read further at your own risk:

We get scant guidance from our professional societies on how to approach these patients.  Our professional societies prefer our immunology complex but our clinical patients simple.  We want to keep our focus on one target organ (the respiratory tract) and one set of triggers (inhalant allergens--preferably pollens).  In short, allergists arguably have some of the narrowest minds in medicine when it comes to thinking of their patients.  Narrow is not good.  Narrow is bad.  Narrow is very bad.  Check out this quote by Konrad Lorenz

Every man gets a narrower and narrower field of knowledge in which he must be an expert in order to compete with other people. The specialist knows more and more about less and less and finally knows everything about nothing.

But allergists aren't the only ones who succumb to the "tyranny of narrowness".  For the allergic patient, narrowed diets are equally bad.  And many allergy patients have them.  The combination of narrowed diets in patients with increased intestinal permeability is a disastrous combination.  Why?  Because narrowed diets promote repetition of foods--often items with high native allergic potential.  As an old engineer, I like to think in terms of system analysis, and formulas.  Here's a formula for you.  A formula that has helped me figure out hundreds of difficult cases over three decades of practice.  You won't see this formula repeated in any allergy society meetings.  I sure haven't.  But it's a killer when it comes to application:

allergic predisposition+ increased intestinal permeability+repetitious/narrowed diets= development of multiple food sensitivities

Check out this flow chart for a more in-depth analysis:

As you might expect, the permutations on this formula are endless.  Just take one item from the left hand box (narrowed diet) and one item from the right hand box (representing causes of increased intestinal permeability), and ...voila!  instant food sensitivities!  Let me present a few cases to you to illustrate what I've seen over the years:

Patient X presents to me with a history of getting sick from "everything she eats".  She had an interesting history--initially had seasonal respiratory allergies, followed by the development of recalcitrant diarrhea.  She finally had a small intestinal biopsy confirming celiac disease.  So she went on a gluten-free diet.  Diarrhea transiently subsided, only to return with a vengeance, AND with the development of worsening respiratory allergies, accompanied by urticaria.  The problem?  Intestinal permeability was enhanced by gluten enteropathy, she stopped gluten--and substituted corn for every snack food and main meal she was eating.  Guess what?  She was highly sensitive to corn.  And I knew this even before I did the RAST test and challenge test to confirm it...

Patient Y presents to me with the development of progressively feeling sick from everything he is eating...He had a history of relatively minor allergies earlier in life, "but he outgrew them" (his quote).  In midlife he went through a period of severe personal stress : New job, divorce, etc. etc.  Limited time to eat, so he began to eat repetitiously the typical "fast food" meals I call "The McDiet".  This was accompanied by liberal alcohol intake, causing increased intestinal permeability.  I knew before testing him that he was sensitive to milk, wheat, yeast, and probably potatoes.

Patient Z had a history of colic as an infant, and trouble tolerating all formulas.  She probably had a dairy allergy at birth, which "went underground" for a number of years.  It resurfaced in hidden form her elementary school years, when she had multiple recurrent respiratory infections, requiring multiple antibiotics.  The cause was missed.  As a teen she took 2 years of tetracycline for acne.  And then?  She presents to me with bloating, gas from multiple foods she eats, cravings for sweets, and fatigue, cognitive dysfunction, and worries about completing her college studies because she feels so bad.   Guess what?  She's got intestinal permeability enhancement from repetitiously eating a primary food allergen all her life (dairy) accompanied by intestinal dysbiosis from recurrent antibiotics later in life.  And her current diet?  The typical college students monotonously repetitive "fast foods" diet.  Not too hard to figure out. 

Clinical pearls:

1.  In the patient with developing multiple food sensitivities, look for causes of intestinal permeability.  It pays off.

2.  In the patient with developing multiple food sensitivities, look for repetitive eating patterns.  Foods with high native allergy potential (eggs, milk, soy, yeast, wheat, corn) would be immediately suspect if eaten repetitiously.

Hope this helps.

Later, dude.   

Have you ever noticed that we humans have a tendency to "solve" a problem--and the solution only gives birth to an even bigger problem?  Examples abound.  For instance, the development of the A-Bomb helped to end WWII...and then nuclear proliferation ensued.  Or, to take another case, we've developed a superior mode of 20th century transportation (i.e., the automobile), only to give birth to massive pollution problems.  And then...we developed antibiotics to end the scourge of infectious diseases, and...?

In my last journal entry, I mentioned that injury and the allergic patient are two things that just DON"T go together well.  Another item that can spell DISASTER for the allergic patient is recurrent antibiotics.  In this series on diagnostic synthesis, I've been discussing a taboo subject--how does a "simple" allergic patient (only one allergy+ one target organ--something which all allergists covet) end-up being a mess, with multiple complex food sensitivities?  One way this happens is through multiple antibiotic useage.  See the diagram below:

                        Let's start in the upper right corner and move clockwise.  Primary allergies such as a simple dairy allergy in early childhood, can lead to recurrent infections (such as otitis media) which in turn leads to multiple antibiotic useage.  Sadly, probiotics are often NOT given concurrently with the antibiotic administration.  Eventually, intestinal dysbiosis (imbalanced bacterial flora, usually with a predominance of commensal Candida species) ensues.  The end result?   Increased intestinal permeability, and subsequent risk for easy sensitization to any food the patient is eating alot of, especially foods with high native allergenic potential, such as wheat, soy, corn, etc.

Another common presentation on this theme is the patient with inhalant sensitivities to molds, unfortunately undiagnosed.  They have recurrent sinusitis as a result, take multiple courses of antibiotics, and present to the office with progressive food intolerances covering a wide-range of items.  Often, they feel sick with everything they eat. 

Now look at the left side of the diagram, starting with "Non-allergic infections".  Sometimes patients have NO prior history of typical allergically-related infections, but have an underlying susceptibility to allergic disease nonetheless.  They have an unfortunate non-allergic medical issue requiring repeated rounds of antibiotics, and wind up with intestinal dysbiosis and the development of multiple food sensitivities.  An example of this is the patient I saw in my office, who was in good health until having severe abdominal pain.  She was diagnosed as having a severely infected gallbladder with sepsis, and was hospitalized and on heavy doses of antibiotics, both during and after hospitalization.  Food reactions rapidly ensued for the first time in her life.

What about the dotted line you see between "non-allergic infections" and "primary" allergies, you ask?  Well, newer research has suggested that recurrent antibiotics in childhood put children at definite risk for developing an increase risk of asthmatic disease.  According to a recent article, Giving antibiotics to a child less than one for a non-respiratory tract infection greatly increases the risk of developing subsequent asthma.  Disruption of the gut flora in early childhood may accelerate/promote the development of "primary" asthma, and possibly subsequent allergy.  This is simply a reworking of the hygiene hypothesis to include the need for healthy gut flora--the so-called "extended hygiene hypothesis".  

Clinical Pearls from all this? 

1.  In the patient presenting with multiple food sensitivities, be sure to check their antibiotic use history.

2. In previously diagnosed allergic patients, try to minimize antibiotics whenever possible, and be sure to give concomitant probiotics when utilizing antibiotics for infections. 

What factor is most responsible for the intestinal permeability increase from disrupted gut flora?  Usually Candida.  But that's a discussion for another time, and another place.  Right now, I'm tired.  How about you?

Later, Dude   

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. 

Most allergists are, to put it politely, "diagnostically challenged" when they see anything other than a runny nose or a wheezer.  Heaven forbid if they need to deal with a patient with multiple symptoms involving multiple body organs.  Most of us don't know where to even begin to unravel the mystery of a patient who says they react to multiple foods, inhalants, and chemicals.  And no wonder.  Our professional societies give us absolutely no guidance in giving us algorithms to use to approach these types of patients.  So I'll give it a try....after all, what have I got to lose when nobody else has had the guts to approach this taboo subject? 

I promised in earlier blog entries that I would present "patterns" I've seen over 27 years in treating allergies.  One pattern I've seen is the patient who presents with a prior history of "simple allergies" in earlier life, who then presents to my office with multiple food sensitivities.  It is the increase in food sensitivities and loss of tolerance to multiple foods that usually brings the patient in for testing and treatment.  Where to begin?  The following outline is designed to help with the process: 

Over the next few journal entries, I'll be using this skeletal template to superimpose the multiple permutations of it that can occur.   The key in this diagram is to focus on  the  cause  of the intestinal permeability  increase, since this is really the cause of the patients  spreading sensitivity to multiple foods. 

An increase in  intestinal permeability can result in increased egress of food antigenic fragments into the circulation, with subsequent rapid sensitivity.  What can cause intestinal permeability increase?  More about that later.  Let me point out one other important thing first.  As this slide indicates, patients can have a shift in their initial "target organ" to other target organs as their sensitivities multiply.  First, they may have simple targeting of the respiratory tract, manifesting as hayfever or chronic sinusitis, and later they may present with multiple sensitivities AND other target organ involvement--myalgias, arthralgias, headaches, gastrointestinal complaints, etc.  In short, it is a characteristic of this patient type that as their sensitivities multiply, they have a simultaneous recruitment of other body organ systems involved in the process. And please note:  specific antigens may specifically trigger different target organs.  In one patient, milk may trigger sinus congestion, and wheat may trigger myalgias and fatigue! 

Over the next few journal entries, I'll be using this skeletal template to "drape" on it the the multiple permutations that can occur with it on clinical presentation.

Later, dude.