When I picked up the phone, I noted the desperation in her voice..."I'm going crazy trying to figure out what's causing my rash", she said.  "I've been everywhere, and no one has helped me..."

...usually I don't have time to talk to potential "new patients" on the phone, but I had an unexpected lull in the office the day she called...just hanging out and reading some journal article about some obscure immunological aberration that I would probably never see in my practice...so when I was paged I took the call.  The more I talked to her, the more interested I became.  "Ive been to xxxBLEEPxxx clinic, and they biopsied the rash and couldn't figure out what it was so they gave me a burst and taper of Prednisone and it still hasn't helped.  And my dentist keeps finding I am getting infections in my mouth for no reason.  I'm a TOTAL mess."  

... Well, at this point I figured I had about 5 minutes of time left on the phone, so I'd take a wild stab at this problem and decided to ask her what most physician't DON'T ask about and DON'T take a history on and DON'T factor into the differential diagnosis--her diet.  "So what do you typically eat?" I asked.  "I'm suspecting I have a food allergy" she said.  When the rash first began, I cut out most foods and now I'm eating green peas, hamburger, and brown rice and the rash is worse than ever..." 

...A thought crossed my mind.  "I want you to NOT change  your diet until I see you in the office," I said.  "And I think I know what's wrong with you.  We need to do a blood test to confirm it..."

...When she came into my office she appeared to be a frail, pleasant blonde who had a rash principally scattered over her lower extremities, but also seen on her back and the nape of the neck.  The lesions were punctate red excoriated areas with shallow scratch marks.  She proceeded to tell me her story, and brought in records for review: 

The rash had been insidious in onset, for about 2 years duration.  Her prior Immunofluorescence biopsy was negative for IgG, IgM, IgA, C3 and fibrinogen.  Skin biopsy reveated no evidence for dermatitis herpetiformis, lichen planus, vasculitis, or immunobullous disease.  There was no lupus band.   She had had fungal serologies and viral serologies, including herpes titers, and these were negative.  She had taken a systemic steroid course, followed by Cortaid application with occlusive dressings which did not help her symptoms significantly.  A boatload of blood work turned up nothing...her ANA, endomysial antibody and tissue transglutaminase antibody were negative (among others) , and she was told she had "neurodermatitis with excoriations". 

Wait...but there's more!  I found out that she would get diarrhea from eating most fresh fruits; she had known this for years:  as a child, she recalled that there was never any fresh fruit in the house  because her mother and sister couldn't tolerate it. Her gums looked somewhat sore.  She had dental problems, and so I ordered a

                         serum ascorbate level

I ran the test thru Mayo Medical labs, and the result was 0.3 mg/dl, with a normal range of 0.6--2.0.. 

Diagnosis? 

                                                Scurvy.  

I placed her on Vit C 500 mg tid, and a general multiple vitamin.   Her lesions healed in a month.  Also, her dentist was happy with me.  And her repeat Vit C level was 2.0. 

What made me suspect Scurvy?  Well, for one thing, her diet of green peas, meat, and rice had no significant Vit C and of course her lack of response to steroids suggested a cause other than immunological inflammation.  Once again, this shows the power of history-taking:  her case was figured out over the phone, and the blood test was merely confirmatory...(so much for her prior "million-dollar workup")

Comments:

There are several "morals to this story", and lessons to be learned:

1.  Not everything that a patient suspects is food allergy is actually food allergy.

2.  A prestigious medical institution missed the diagnosis because no one had bothered to take the patients dietary history.  And the cost (emotionally and financially) to the patient was enormous...

3.  She (and other family members) probably had a hereditary fructose intolerance, and she was probably marginally Vit C deficient her whole life, and then when the rash began, she restricted her diet further, taking out the vegetables out of her diet that were buttressing her Vit C level, and her skin rash and dental absesses began...

4.  Just because she had Scurvy didn't mean she was ONLY deficient in Vit C.  She desperately needed general vitamin repletion.  (I quickly checked a Zinc level with her dental problem as well, and she was also deficient in this).

5.  As allergists, we need to be aware of nutritional deficiencies for our patients.  It's not enough that we are "asthma doctors."  This patient wouldn't have been helped with inhalers or antihistamines.  Period.  

5.  If we're good doctors, we'll get more of our "bread and butter" allergy patients.  Ironically, this "non allergy patient" has referred me patient after patient for allergy care!

Later, Dude 

I've just finished reading "The Hound of the Baskervilles" for the umpteenth time...I love detective stories, and I especially love the archetypical detective, Sherlock Holmes.  And in the following case history, one of Holme's axioms is employed--here it is, repeated multiple times in various settings:

 "Eliminate all other factors, and the one which remains must be the truth" (from The Sign of Four)

"How often have I said to you that when you have eliminated the impossible, whatever remains, however improb able, must be he truth" (again, from The Sign of Four) 

"When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth" (from The Adventure of the Blanched Soldier)

"We must fall back upon the old axiom that when all other contingencies fail, whatever remains, however improbable, must be the truth" (from The Adventure of Bruce-Partington Plans) . 

Keep this Sherlockian rubric in mind with the next story...it'll pay off...

...Besides reading books, I also like to read newspapers--they're full of interesting stuff.  So I was especially intrigued by the newspaper headline "Mystery Illness Plagues Former Pentagon Worker".  I was even more intrigued when it was handed to me by my new patient, a young woman walking unsteadily with a cane, which appeared incongruous in such an attractive, young individual.

She had a litany of complaints--well described in the newspaper article about her case--a cornucopia of neurologic and "allergic" symptoms:  Burning and numbness in her extremities, balance difficulties, muscle spasms and twitching, , chronic mucous in her throat and sinuses...as well as more systemic complains of  chronic exhaustion and  cognitive dysfunction.  There were gastrointestinal symptoms too, including  mucous in her stool, and diarrhea.  If I picked an organ system, she seemed to have a symptom in it.  (The dreaded "positive review-of-systems" that most doctors recognize). 

The only thing bigger and longer than her list of complaints were her prior medical records--she had worked for the Pentagon, and there was page after page of diagnostic tests by impeccable Washington medical institutions, with test result after test result.  But no firm diagnosis had been made.  I  decided to do something totally radical--I put all her prior test reports aside, and decided I'd take her history myself.  And her history was interesting too:  She knew she had allergic disease earlier in life--and she came to see me to see if there was any "tie-in" between her current plethora of symptoms and allergies.  In the 1990's she had episodes of recurrent/chronic sinusitis and tonsillitis.  Prior allergy testing via RAST had shown positive results to dust mite, Kentucky blue grass, elm and cottonwood.  She had a history of classic seasonal allergic rhinitis causing quite a bit of throat, nose, and eye irritation for which she had periodically used fexofenadine.  However, all of these issues were perceived by her as being relatively "minor" issues until November of 2004, when troubles really began...

In November of 2004, while working at the Pentagon, she ate what she thought in retrospect was some contaminated fish and had a sudden, protracted episode of gastroenteritis.  As the months wore on, she had recurrent episodes of further diarrhea and abdominal cramping, followed by some constipative tendencies.  By October of 2005 she was having trouble getting up in the morning and progressive malaise and fatigue were setting in.  In November of that year she began to develop pain in her lower back and hips, and she experienced difficulty walking.  She again saw her physician, who at this time felt she might have pelvic inflammatory disease, despite negative cultures and a monogamous marriage.  She was given Flagyl and Levaguin, and began to feel markedtly worse within 24 hrs.  She began to have bilateral paresthesias in her legs and hands, and her feet ached and her grip got weak, she got progressively weaker,  and was hospitalized and had a thorough neurologic workup.  An LP, EMG, MRI of her brain and spine were all negative.  Celiac disease was ruled out.  She was given  IVIG and a preliminary diagnosis of "atypical laboratory negative Guillian Barre Syndrome".  Of note is the fact she had a rash on her hands while hospitalized which she described to me to be suspiciously like the distribution of an "Id reaction."  Her neurologists, however, were puzzled by the fact that she "should be getting better" and she had a very protracted convalescence, with a 3 week stay in the National Rehab Hospital. 

She never returned to her job at the Pentagon, and in April of 2006 moved to the midwest, where another neurologist there took over her case, and again extensive neurologic tests were run, without a firm diagnosis being made. She became  self-employed as a Defense Contractor Analyst, but because of her multiple symptoms, she was barely able to function on a day-to-day basis.  

Physican exam:  Positive Chvostek sign, positive Romberg, nasal drainage.

Medications:   omeprazole, skelaxin, dilaudid, meclizine, oral contraceptive

Diet history:   Craves chocolate, steak.  Has sweet tooth.  Favorite foods pasta and beef.  Very heavy wheat ingestion. 

Intradermal testing by IDT:

Grass Pollen:   11 mm dil #5

Ragweed:       16 mm dil #3 

Dust mite:      10 mm dil  #4

Tree mix:        9 mm dil# 3 

Oral Challenge testing:

Gluten:     dizzy, lightheaded

Milk:         cognition impaired, unsteady in walking; shakey legs

Beef:        cognition impaired, legs tingling & shaking

Candida:  very tired, aching in legs and shoulders, legs shakey

RAST test: 

IgE:  Negative to:  milk, wheat, soy, tomato, beef, yeast, potato, garlic, onion, gluten 

IgG:  Class II:  milk, Candida, beef, garlic  

        Class i:  wheat, soy, tomato, potato

        Negative:  onion, gluten

So what's going on?  

Again, the beauty of understanding diagnostic synthesis in complex allergic diseases is that you can make sense of a history, that superficially, is horrendously complex and puzzling. After I took this history, here's how I put it together chronologically:

longstanding history of inhalant allergies, leading to

recurrent sinusitis, leading to

recurrent antibiotic use, leading to

excessive Candida growth--

acute food poisoning reaction in 2004--chronic intestinal inflammation with enhanced intestinal permeability, leading to

Candida sensitization (and possibly food sensitization at that time)

Levaquin and  Flagyl given, with drug reaction occuring, and further Candida growth

Id reaction in hospital is further evidence of Candida sensitization

Underlying grass pollen sensitivity sets her up for cereal grain sensitization in presence of leaky gut syndrome; may have had a longstanding milk allergy all her life, made worse with leaky gut; 20 percent of people sensitive to milk react to beef, and she sure did!

Furthermore, her chronic diarrhea and Candida overgrowth set her up for a serious magnesium depletion state, with a positive Chvostek sign on exam and multiple muscle spasms throughout her body.  Peripheral vasospasm contributes to neurogenic ischemia, aggravating her paresthesias.   

All of this can be deduced by her history, before any allergy testing is done.  

Treatment Plan: 

She obviously wouldn't be a candidate for SCIT--she's too unstable, and has too many neurological symptoms.  She's a great Candidate for SLIT, however.

Plans--

1.  Rotation-elimination diet to reduce antigenic burden:  avoiding milk, beef, refined sugar, wheat gluten

2.  Fluconazole with probiotics to reduce Candida antigenic burden

3.  SLIT to inhalants , treating her dust, ragweed, grass, pollen, tree, and Candida sensitivities (note--she had scarring from her Candida and TCE injection sites, and dosing was given for Candida only after receiving information on her delayed reports, to avoid overdosing, and using the strongest negative delayed reaction wheal on her Candida IDT)

4.  SLIT to foods--gluten, milk, beef 

5.  Magnesium Chloride Elixir, 12.5%, 2 tsp orally per day for magnesium repletion

Clinical Course:

When she returned to see me 3 weeks after her first visit, she still had scars on her arm from the prior Candida & TCE IDT tests, but she was feeling much better.   Her balance was dramatically better, and she was no longer using her cane, and had stopped her meclizine, dilaudid, and had reduced her Skelaxin.  Her gastrointestinal function was markedly improved, and the generalized burning in her torso was gone, and her energy and cognition were dramatically better.  I last saw her informally in our hallway 2 weeks ago--this was about a year after I had first seen her; her symptoms were in complete remission, and she was now pregnant.  She was bringing in...guess what...another friend of hers, a young nursing student, for assessment for idiopathic chronic fatigue and aching issues...and the beat goes on...

Important points to ponder:

Were this patients neurological symptoms related to "allergies?"  And before you're too quick to pass judgement, remember the Sherlockian phrases I listed above.  Read them again.  Then reconsider. Neurological manifestations of allergic disease states are a great unexplored frontier.  And this is a tragedy--and one of our own making, I might add, because of our arbitrary demarcation of allergic disease to the respiratory tract. Should we, as allergists, be more interested in neurologic manifestations of allergic disease?

It's Elementary, my dear Watson.

Later, Dude