"In 1930, Vaughan, in collaboration with Frances Wilson, an academic botanist, initiated studies of shared characters of plant-derived foods as the first stage in the development of a classification intended to serve as a rational and workable basis for selecting test allergens representative of members of a group.  ...Of special interest is a 75-year-retrospective review of Vaughan's contribution, noting that with few exceptions his compilation was valid and met the test of time"  

 As a Renaissance Allergist, I have an interest in classical (medical) literature, and an overwhelming sense of curiosity--basically, what else did Vaughan write--and what might it tell us in addition to Cohen's article? 

Here's some things not pointed out in the article by Cohen:  

First, Vaughan wrote on a wide range of topics he felt were related to the allergy field:  check these out:

1.  Vaughan, WT.  Allergic Migraine.  JAMA 88:1383, 1927.

2.  Vaughan WT.  Role of specific and nonspecific factors in allergy and allergic equilibrium.  J Lab & Clin Med 13:633, 1928.  

3.  Vaughan WT.  Allergic factor in mucous colitis.  South M J 21:894, 1928.

4.  Vaughan WT.  Atypical and borderline allergic manifestations as important factors in general medicine.  South Med & Surg 95:15, 1933.  

5.  Vaughan WT.  Food allergy as a common problem.  J Lab & Clin Med 19:53, 1933.

6.  Vaughan WT.  Food idiosyncrasy as a factor of importance in gastroenterology and in allergy.  Rev Gastroenterol 5:1, 1938.  

7.  Vaughan WT.  Palindromic rheumatism among allergic persons.  J Allergy 14:256, 1943.

Secondly, we know Vaughan was a brilliant physician.  ( For anybody to get their picture in the JACI, you've got to be brilliant).  Even his son was a brilliant doctor--John Heath Vaughan, was an internationally recognized authority on allergy and autoimmune diseases and a former member of the University of Rochester School of Medicine and Dentistry, who recently passed away at the age of 85 on Nov 11, 2007.  So why was  a brilliant physician like Vaughan writing about palindromic rheumatism and it's relation to allergy?  What does his "classical" writing tell us?  Are you curious? I was. 

In his article, Vaughan described 27 cases with recurrent or chronic joint symptoms among a large group of allergic patients, in whom the arthritic symptoms were attributed to food sensitivity.  He called this syndrome "palindromic rheumatism", a term used by Hench and Rosenberg 2 years earlier to imply recurring joint disease without articular residue.  Vaughan would note that about half of his patients seemed to have abnormal joint changes at the time of exam.  His original discription of this group of patients is repeated here for its remarkable accuracy:

"The second consideration was a small group of allergic persons with intermittent attacks resembling subacute rheumatoid arthritis in whom we have demonstrated specific food incitants.   The evolution of the attacks resembled those of intermittent hydroarthrosis, but multiple small joints were involved; often just one hand or foot was affected.  Sometimes the reaction occurred in more than one extremity, and at times one or two large joints became inflammed either simultaneously or independelty.  The local picture was of swelling, redness, paind, and tenderness.  The attacks would last from several days to a week, rarely longer.  In some, the joints were objectively normal between attacks.  In others, there were low grade arthritic changes..."

Now--be honest--how many allergists take rheumatic histories on our patients?  I do.  For example, I can remember the patient with a strong dust sensitivity who suffered an acute attack of palindromic rheumatism after sweeping out her basement.  In truth, being curious and delving into the older "classical" allergic literature---which was devoid of the built-in constraints of IgE-mediation, may offer us new insights.  Remember what I wrote last month about the mast cells and the synovium?  

Warren T. Vaughan was a Renaissance Allergist.  A brilliant clinician.  And he believed that palindromic rheumatism could be triggered by food incitants.  Renaissance Allergists in today's world need to follow-up on his meticulous & compelling observations. ...

Later, Dude.  

                          Renaissance

The word "renaissance" is of French derivation--for rebirth.  What characterized the Renaissance?--a "rediscovery" of classical literature/art, curiosity and objectivity, and an emphasis on individualism (among other things.)  The true "Renaissance Man" embodies these ideals in a multi-talented fashion.   In my (humble?) opinion, the allergy field needs more "Renaissance Allergists", and alot less "asthma docs".  We made a fundamental mistake as allergists when we anatomically delimited our field--because the field is basically not one to anatomically demarcate.  In that respect, it's alot like our "brother specialty"--infectious disease.  Imagine if the IDSA  (Infectious Diseases Society of America) changed their name, for example, to emphasize "bronchitis", and became the Infectious Diseases Society of America and Bronchitis?  What if you went to infectious disease meetings, and all they talked about was the respiratory infections they cared about?  How interesting would that be?  We've done that with our own societies--tagged "asthma" along with the official titles, as if to say that's "who we are". Asthma docs. 

And that's what the Renaissance Allergist is not.   What is he?  Easy.  He's a multi-talented physician first, an allergist second, and an asthmalogist (a distant) third.  He/she is interested in all immunological aberrations (both non IgE and IgE mediated) over all mucosal surfaces, as well as the skin and joints.  And come to speak of it, he's even interested in the human synovium, and how his allergic patients might respond there.  Remember--mast cells have long been known to be present in the human synovium, and mast cell numbers also increase 1-10 fold with diverse disorders, including juvenile and adult rheumatoid arthritis.  (See "Mast Cells and arthritis"  by Malone & Metcalfe, Ann Allergy 61:  27-30, 1988 if you're interested).  Yes, a spirit of curiosity, individualism, and love of classical literature are characteristics of the Renaissance--and of the Renaissance Allergist. 

Which brings me to the latest Allergy Archives, and Warren T. Vaughn.  But that's for another time, and another post.

Later, Dude

half-full glass of water...                                                                                     Is the glass half full?  Or half empty?  Which is the MORE accurate perspective?  Which viewpoint  tells us more?  In the field of allergy, the Angry Allergist has been concentrating on our shortcomings...and rightfully so.  We have a bucketful of them. I've outlined them in my "Allergy--a field in trouble" monograph in the right menu column.  In short, I've portrayed the Allergy Glass as pathetically half-full, or maybe even empty.  On the other hand, as I read our official allergy society newsletters, I've been greeted with moronic platitudes like "Nobody does it better than the Allergist"--and a marketing campaign dedicated to telling patients to see their local allergist for the best in allergy care.  This perspective treats the glass as completely full. Nothing more needed.  As allergists, we have all the knowledge and tools to effectively help our patients, even if we utilize our best tool--immunotherapy--in less than 20% of them.  Well, who's right? Is the glass half full, or half empty? 

 I've been looking for a word--a single word--that typifies what we need in the field of allergy--something typifying the act of "filling the glass".  Something to describe in a positive fashion what we--as a field--need to do.  And be.  And not what we lack. What word? 

 Renaissance.  

And I'll talk about why I chose this word.  And what it means for us as a specialty.  Because we need, desperately, to fill the glass.  Yes, it's probably half full.  I'll give you that.  But it wasn't designed to be half full.  And that's the point.    Let's fill 'er up.  And, like real life (at $4+ bucks a gallon)--it may be painful, but it's got to be done...

Late. Dude

Please Note:  When you come back to this site, you'll need to point your browser to a new web address:  www.renaissanceallergist.com. 

...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 

You already know where I stand on the importance of case reports; in my prior entry on The Iatrogenic Atrophy of the Case Report, I gave a Case Report on...you guessed it...the Case Report--since The Annals of Allergy Announced they were no longer going to accept unsolicited case reports in their journal. So here's another unsolicited case report, which I'm publishing online, to outline the versatility of  SLIT in treating a complex case of allergic disease...

Case Report 

Patient X was referred to me by a local allergist on January 4, 2007.  This 20-something patient was referred by her allergist to me, principally to help deal with a loss of food tolerance and progressive food sensitivities.

Background history: 

Patient X had a history of eczema transiently as a young child, and had a lifelong history of asthma beginning in childhood.  Throughout childhood she had recurrent sinusitis.  She was treated symptomatically with antihistamines, and steroid inhaler medications, and overall was doing acceptably well in her teenage years.  As a college student, she was under much stress, working 15 hours part-time and taking 15-18 hours of college credit per semester.  Things were going well until...

The fall of 2005 she suffered from a serious aggravation of upper and lower respiratory tract allergies in Sept & October, followed by bronchitis in October and November.  In December 2005 she developed her first migraine headache, and migraines have been bothersome since then. Interestingly, they were helped partially with benadryl useage...

Not only were migraines bothersome, but in the fall of 2005 she began to notice nausea, satiety, and general stomach distress with eating.  She reduced her food intake and lost about 40 pounds.  Her stomach distress was significant enough to keep her from concentrating on her academic studies. In December of 2006  she had formal gastrointestinal  evaluation;  esophageal biopsies  demonstrated short segment  Barrett's,  and mid-esophageal biopsies demonstrated 25 eos per HPF, borderline for eosinophilic esophagitis.  Her gastric emptying study demonstrated a mild delay to solid phase gastric emptying. 

Past medical history:  Remarkable for multiple concussions playing basketball, with heavy NSAID use; infection while traveling overseas requiring doxycycline useage for 2 months, June-July 2006. 

Prior Allergy Testing & Treatment 

Her referring allergist had enclosed records from still ANOTHER allergist (!!), who had previously done prick testing for inhalants, revealing strongly positive ++++ pricks to ash, aspergillus, curvularia, fusarium, pullularia, rhizopus, stemphylium, mucor, and +++ prick tests to dust mite, alternaria, botrytis, ragweed. 

Prick testing to foods revealed ++++ pricks to corn, +++ to carrot, soybean.   

RAST testing had revealed IgE class I to corn, banana, almond, potato, and soy.  Additional RAST testing had revealed IgG class IV to casein, corn, soy, and IgG III to wheat. Gliadin antibody to wheat was negative. 

She had peripheral eosinophilia at 8%.   

She did not receive immunotherapy. She initially tried to eliminate wheat and corn from her diet, and noted a reduction in migraine headaches for about one month, only to return with a vengance after that.  

Status on Presentation 

Patient's X's major goal was "to help my health so I can complete college."  She had lost 40 pounds, and was afraid to eat.  She had dropped out of school because of her multiple illnesses.  She had chronic migraine headaches, and continual stomach distress.  She was afraid her asthma would again act up in the fall and cause even more problems, but on a day-to-day basis she struggled with frequent migraine headaches and stomach upsets.    

Medications on arrival:  Allegra 180 mg/d, Topamax 50 mg BID, Prevacid 30 mg/d, Advair 500/50 1-2 x per day, depending on season, albuteral prn, midrin prn, skelaxin 800 prn.   

Current diet:  avoiding wheat, corn, corn, milk, beef, soy, bananas, carrots, rye, pork, MSG.  Craving peanut butter.   

Physical Exam:  remarkable for nasal turbinate congestion, coated tongue, cold hands with poor capillary filling.  Lungs clear at time of presentation.  No hepatosplenomegaly or localized abdominal tenderness.

Our Initial Test Results:   

IDT Testing: immediate test results

dust:             9mm       dil #4

Ragweed:    15 mm      dil #5 

Grass:          11 mm      dil #5 

Alternaria:  11 mm      dil #5 

Fall pollen   10 mm      dil #5

Candida       11 mm      dil #1

Mold mix      10 mm      dil #3

Rast Tests: inhalants

Kentucky/June grasses:               IgE Class III

Alternaria mold:                         IgE Class III

Ragweed:                                   IgE Class III

Rast Tests: selected foods in diet currently eating

Egg:                                            IgE Class II

Pea                                             IgE Negative          IgG Class II

Peanut                                        IgE Class I

Almond                                       IgE Class II             IgG Class III

Tomato                                       IgE Class II             IgG Class III

Potato                                        IgE Class I              IgG Class II

Chicken                                      IgE Negative

Candida                                      IgE Negative         IgG Class III

Oral Challenge Testing:

Peanut challenge--immediate severe migraine (eating daily)

Egg challenge--immediate exhaustion (eating frequently)

Potato challenge--immediate sinus pain and pressure

Milk challenge--stomach distress

Candida challenge--exhaustion 

Assessment & Discussion:

On the "surface", this patient suffers from multiple problems:

1.  Bronchial Asthma
2. Seasonal Allergic Rhinitis
3. Recurrent sinusitis & Bronchitis
4. Chronic gastrointestinal distress, nausea, anorexia
5. Migraine Headaches
6. GERD with Barrett's esophagus
7. Eosinophilic Esophagitis (borderline)
8. Gastrointestinal hypomotility
9. Multiple food sensitivities
10. Multiple inhalant sensitivities
11. Oral allergy syndrome from fresh carrots, bananas
    

However, it's necessary to use a chronological, "flow-chart" approach to really appreciate what the hell is going on.  Believe it or not, getting an "integrated" view of this case isn't really that hard if you go back to some of the principles I outlined in my prior entry Diagnostic Synthesis in Multiple Food Sensitivities.  Basically, here's how I saw it on the first day I saw her: 

She has had a lifelong history of multiple allergic sensitivities, beginning in childhood with  manifestations of eczema and asthma.  These were not treated with disease-modifying immunotherapy, but "patched up" with inhalers, antihistamines, etc.  Her high-stress college-environment made her susceptible to a flareup in her allergic condition and a further "allergic march to other organ systems.  In fact, it turns out she  had an allergic march through her life--not just the usual respiratory "allergic march", but a VERTICAL allergic march involving her GI tract and Neurological systems (migraine) when she hit the fall allergy season and had an overload of ragweed and alternaria exposure. 

She had enhanced permeability brought about by high NSAID useage and Candida overgrowth.  (Prior concusions and high NSAID use followed by 2 months of doxycycline immediately before the onset of her symptoms).  Enhanced intestinal permeability subsequently caused aspread of food sensitivities during the fall mold season; Candida growth was further aggravated by the additional antibiotics she took in the later part of the fall for bronchitis.  Since enhanced intestinal permeability was her real problem, it didn't surprise me to hear she was only temporarily better on a wheat and corn free diet.  It didn't surprise me she had a migraine triggered by peanut on her first visit, since this cross-reacts with soy protein, already a formerly diagnosed food allergen.  (The beauty of food challenges is you can actually see what "target organ" is affected by a particular food.  For example, peanut triggered a migraine, but milk triggered intense stomach upset.)

Treatment Plan 

This involved 3 major areas:

1.  Improve intestinal integrity:

     ---Probiotics, oral cromolyn sodium, and short-course  fluconazole

2.  Reduce inhalant and food sensitivities with immunotherapy:

      ---SLIT immunotherapy to inhalants & foods (including all molds), titrated off RAST & IDT tests

3.   Offer patient food choices in a structured manner, since she was afraid to eat anything when first seen:

      ---Rotary Diversified Elimination Diet avoiding initially wheat, peanut, soy, carrot, banana, melon, egg, almond, pork, milk, corn, tomatos, MSG but allowing other foods on rotation

4.  Prevent a recurrence of a "crash" in the fall of 2007, like she had in the fall of 2006, by using highpotency preseasonal Ragweed treatment. 

Clinical Course:

We had first seen this patient on Jan 4; by Feb 5 (one month later) she her migraines were in complete remission and she was feeling well enough to return to school and complete her course requirements.  On her March 5 visit she related she had 1 migraine (stress from midterms).  She found improved food tolerance on SLIT, and at that point was able to reintroduce milk and beef back into her diet on rotation.  By May 2007 she was able to taper off of gastrocrom, and able to handle most foods, but still had problems with wheat and soy.  Her eosinophilia of 8% had improved by July to 2%.  She took high-potency preseasonal Ragweed treatment for 6 weeks before the ragweed season.  When she was last seen by me in November, she related she had an excellent fall allergy season, especially in light of camping out 3 weekends in August!  She was delighted she did not have her bronchitis episodes in the late fall like she had last year.  Food tolerance continued to improve, migraines were in remission, she was gaining weight, and only used gastrocrom when eating out at restaurants but still took SLIT for inhalants and foods faithfully.  She was off of Advair ("I don't need it") and her FEV1 was 4.546, 116% of predicted. 

Important Points:

There are actually several points to be made with this Case Report:

1.  Bad things can happen to a patient with multiple allergies who receives no disease-modifying immunotherapy approach, especially if their allergic "load" continues to build in a hidden fashion.    

2.  The "allergic march" can include not only the classic upper/lower respiratory tracts and skin, but also the development of neurological symptoms, including migraine headaches, and (arguably) eosinophilic esophagitis.

3.  The concept of a "critical allergic mass" is important in this case--the patient began to decompensate during the fall ragweed/alternaria mold season, when the additional load of inhalant allergens on previously existing occult food/Candida sensitivities put her in an "overload."

4.  Enhanced intestinal permeability needs to be addressed to stop the spreading of food sensitivities.

5.  SLIT can be safely used, even in patients who are polysensitized.

6.  Eosinophilic esophagitis is one more manifestation of a broadening allergic picture in this patient, rather than a totally distinct issue to be dealt with separately.  Interestingly, I have had one more patient (a doctor's son) treated with SLIT for eosinophilic esophagitis, who had a repeat biopsy confirming complete remission (the current patient has not had a repeat biopsy). 

7.  High-potency preseasonal ragweed SLIT helped the patient enjoy a healthy fall allergy season, with no recurrence of previous chronic bronchitis or other serious respiratory illness.

Her referring allergist was initially skeptical of SLIT useage, indicating in his first letter to me that "I would be somewhat hesitant to use SLIT, taking into account her current gastrointestinal complaints."  His most recent letter to me is as follows:

"I am very impressed with your management of patient X.  You and your staff have done a very nice job in managing a patient who is difficult to manage with the standard allergy management.  Keep up the good work.  

 It is gratifying to have tools to help complex patients such as this.  SLIT is one of them.  

Later, Dude   

"I am an Italian allergist and I have read with much interest your reply to the title "we need more allergists" from the ACAAI.   I agree with nearly all your points about the shortcomings of today's allergists, but I think that you are wrong in one point:  the idea that the answer is SLIT.  As you know, SLIT in Europe and particularly in Italy is widely studied, prescribed, and used.  But the problem is that some companies producing SLIT are offering this treatment to general practitioners and family paediatricians, hoping to increase in this way the number of prescriptions.  In Europe in the next years SLIT will be available in the public pharmacies, just like anti-histamines, etc.  In my opinion, and in the opinion of nearly all Italian allergists, we do have to go back to immunological control and immunotherapy, as you correctly state, but in order to differentiate our profession from other specialists the answer is turning to subcutaneous immunotherapy, especially now the new biotechnological products, such as recombinant immunotherapies, are really around the corner.  Congratulations for your site and happy new year!"

Awesome letter.  On several points.  First and foremost, he likes my site, so this means of course he's truly an intelligent and discerning individual.  But beyond that he raises an interesting question--is SLIT truly "the answer" for the allergy profession, when it will be available for seemingly everyone to use--patient, family physician, pediatrician, ENT physician? 

On one hand, we can treat a larger proportion of our patients safely with SLIT, but is this meaningless if we get no referrals because everyone else is doing it?   In a sense, the author poses a large and critical question--The Allergist and immunotherapy:  Quo Vadis?  The author above apparently feels that injection immunotherapy (SCIT) is "the answer", since he states "in order to differentiate our profession from other specialists the answer is turning to subcutaneous immunotherapy, especially now the new biotechnological products, such as recombinant immunotherapies, are really around the corner."  I take exception to this view, for several reasons:

1.  On a practical basis, when SLIT is available over-the-counter, many people will logically use this first, before going to an allergist. If they get relief, they'll stop there.  If they don't get relief, or have side-effects from SLIT, then they'll see an allergist.  Are these "tough cases" the ones we want to put on SCIT, after they've had side-effects from SLIT or not responded?  If they had side-effects from SLIT, they will likely have side-effects from SCIT--probably more severe.  If they didn't get relief with SLIT for (as an example) grass pollen, then they might be unstable and polysensitized, for example, to grass AND mold--again, not an ideal SCIT population to treat. 

2.  It's hard to "market" SCIT to a patient population and emphasize they should see an allergist for it, when there is SLIT available over-the-counter, as the author mentions, in the very near future.  SLIT is just too damn  convenient.  I talked about this in an earlier blog entry when I likened SCIT to "painting" and SLIT to "photography".  We still use both in our society, but one technique is used alot more--because of its ease, convenience, and cost-effectiveness.  (See entry One picture is worth a thousand words:  immunotherapy, painting, and the birth of photography) 

3.  SLIT is more versatile than SCIT.  And it's versatility, like Rodney Dangerfield, just "doesn't get respect".  SCIT just doesn't work for molds, and SLIT does.  SCIT just doesn't work for late-phase reactions, and SLIT does.  SCIT hasn't been shown to work for foods, but there's emerging evidence that SLIT works for foods.  Multiple protocols should be developed for SLIT--and we use these in our office. 

4.  Granted, recombinant immunotherapy is attractive and sexy, but it's way farther back than SLIT for approval--at least in our country. 

The author is truly correct in that--technically speaking-- "SLIT is not the answer".  I'll tell you what is:  Doing SLIT better than everyone else.  And I mean everyone. 

I've used SLIT for 27 years, with multiple protocols--high dose European-style and IDT low dose for late-phase mold allergy.  As times change, I  have increasingly seen patients on SLIT from other practitioners who have failed treatment--and we have to offer them more than SCIT to help them. The "next-generation" allergist better be ready for these patients!   Example 1:  A patient on low-dose SLIT from a practitioner treating her for mold allergy, when her real problem was a moldy home and inadequate SLIT dosing. SCIT wouldn't have helped this patient at all.   IAQ improvement in her home, and higher dose SLIT for molds did.  Example 2:  A patient not getting relief on SLIT from another pracitioner because of an undetected food yeast allergy in a patient who was mold sensitive.   Again, SCIT wouldn't have helped this patient. And SLIT did. 

Finally, It's always risky to differentiate our profession from another by just a technique--and that's all SCIT and SLIT are---techniques.  Tools.  It's not the hammer and nail that make the carpenter, it's the other way around...We not only need to be the best at delivering immunotherapy, but we need to be the best diagnosticians around--for all allergic diseases, not just asthma.  This (I guarantee you) will make patients come knocking at your door.  See my entry "How we can fix it" for more. 

The Allergist, immunotherapy:  Quo Vadis?  The answer to this question will determine the direction of our specialty and its survival in the future. 

Later, Dude 

Ever feel like the Odd Man Out? I have. And it's not a nice feeling. I have a painful memory from grade school--sides were being chosen for baseball teams. There I was, waiting expectantly to be chosen. My hopes gradually diminished as all the other boys were chosen, and finally I was left over, with no one wanting me. I was the odd man out. Not a nice feeling, to say the least.

Well, when we think of baseball, what do we naturally think of? Steroids, of course. And who uses steroids the most? Allergists, of course. We have our patients sniff, inhale, swallow, and lather on more varieties of steroids than Barry Bonds ever tried. But all the steroids in the world won't keep us from being perceived as "the odd man out" by our primary-care medicine colleagues.

You see, many allergists today are "the odd man out" in managing the allergic patient--increasingly, everyone BUT the allergist (i.e., the family physician, pediatrician, ENT physician, internist, dermatologist, chiropracter, etc.) get to "manage" the allergy patient, and the allergist is left with empty hands (and an emptier pocket book). Why is this?  Why is the allergist the Odd man out?

Sometimes the truth is ugly. And uglier to face. Getting back to my own childhood experience in being the "odd man out" for baseball teams, I hated the players who were chosen before me, and thought the whole system was unfair. Truth-be-told, I wasn't a good baseball player...in fact, I was a disgrace to the National Pastime. I wasn't chosen because (and get this)--I had nothing to offer either team in the way of talent (or motivation) to make sure our team "won". The Team Captains had nothing personal, mind you, against me--that's just the way they saw it....

Well, how do our colleagues view our specialty? How do they perceive of us?

Easy--just look at the poster picture of 'ol James Mason in the above movie poster. He's a real energetic ball of fire, right? Read the print under the title and picture:  "with his back to the wall, in the tense, taut, tormented role of his life".  Well, Sydney, that's how most primary care physicians perceive allergists.  Don't agree with me?  Then you haven't talked to multiple primary care physicians in quite a while.  Are you furious with the Angry Allergist? Tough.  Get a reality check.  Suck it up. 

Because it's true. 

Here's a thought: maybe the majority of patients don't get an allergy referral from the family physician, pediatrician, or internist because we're perceived of just like I was perceived as a young baseball player--i.e., somebody who doesn't bring a valuable asset or unique talent to bear on the issue at hand.

In order to be a part of the family practice/internist/pediatrician "team" we have to "bring to the table" some tools/techniques/assets to help the patient beyond the usual steroids, antihistamines, etc. that primary care physicians themselves can use. They have to "perceive" of us as offering something more than what they can offer. Then--and only then--we will be "invited to the table" and be part of the team of health care management for our patients. Will an expensive marketing campaign telling patients and doctors that "nobody does it better than the board-certified allergist" work? Of course not. Patients and doctors are too smart for trite platitudes--as one physician assistant told me, he doesn't refer to allergists because he quickly found out that they really didn't offer anything more in the long run than what he himself did medically.

Well, how can we become "a team player" and not "the odd man out?"

For one thing, let's put 5 ideas down and see what shakes out:

1. The Allergist is the odd man out.

2. The internist/pediatrician/family practice community perceive the allergist as not offering anything unique and helpful to the management of their patients.

3. Immunotherapy--something unique that allergists do and is potentially disease modifying--is offered to only a minority of allergy patients by allergists.

4. A safe, effective, painless and convenient form of immunotherapy--if available--could revitalize the allergist's relationship with primary care physicians, and make him a team player.

5.  This form of immunotherapy is already available:  in SLIT. 

I find it incredibly ironic that items #4 & #5 above are being approached by  the American allergy community in an unbelievably overcautious, defensive posture.  Hey guys--get real--this is the ONLY thing that has a chance to revitalize our sick profession.  We'd be able to offer more patients safe effective treatment (Sublingual immunotherapy, i.e., SLIT)--which is something that the average pediatrician, internist, or family physician can't do.  Now THAT could engender referrals better than any slick Madison Avenue Campaign.  In short, SLIT can in my opinion completely revitalize an allergy field full of tired old symptomatic treatment with inhalers, antihistamines, and creams.

We should be falling all over ourselves doing American-based studies, and promoting SLIT. I mean we should be so manic about this topic we should be SICK of it.  After all, can over 100 European studies on SLIT be wrong? 

So, we have a choice as allergists:  Develop ourselves into a specialty that deserves referrals from primary care physicians.  Develop and enhance immunotherapy protocols--specifically SLIT--and do more of what should really define who we are:  immunotherapy.  Or...continue to push the latest inhaler du jour, the most brightly colored antihistamine,  and remain...the Odd Man Out.    As for me?  I've been Odd Man Out once in my life--and once was enough.  

Later, Dude 

It was with bittersweet amusement that I read the "Allergist Report:  America Faces an Allergy/Asthma crisis," dated April 2007.  The report makes a number of unsubstantiated statements in an attempt to persuade that a critical shortage of practicing allergists is eminent....I am troubled by the committee's obliviousness to real-life factors, such as primary care physicians' reluctance to refer to specialists, (as well as)  otolarynologists, pulmonologists, primary care physicians, chiropracters, and alternative medicine practitioners practicing allergy...it should not be forgotten that most patients with allergic disease and asthma never see an allergist.  Also, training more allergists will do nothing to encourage the new allergists to seek out underserved areas, typically rural and undesirable, to practice in.  I believe it is shortsighted and irresponsible to encourage more training program slots in a specialty that is underused..."

So Rodney, this Bud's for you...and you have given the Angry Allergist the inspiration for a new award that will be given by me to original-thinking Allergists.  Allergists who don't go with the crowd.  Allergists who aren't, as our California Governor put it, "girlie-men".  Allergists who don't follow the herd--they shoot the herd...Allergists who aren't afraid to strip to the waist, put on a headband, pick up a fifty-caliber and let the Allergy establishment have it...you guessed right...

The Angry Allergist Rambo Award.  For Allergists.  Allergists who can kick ass. 

And when Rod called the committee "shortsighted and iresponsible" , "oblivious to real-life factors" he just grabbed, without realizing it, The First Rambo Award.  The first, I hope, of many more to come....

Congratulations, Rod.  Enjoy your award.  Then, let's lock 'n load, buddy; we've got work to do...  

Later, Dude 

P.S.  Female allergists will have their OWN award.  Coming soon to a browser near you...

Now, I realize some of you are 5 sentences ahead of me already..."man, now he's accusing allergists of not being compassionate to patients--this time the Shock Jock of Allergy has gone too far."  Well, before you degranulate all your mast cells...hear me out...but I warn you, the Shock Jock will nevertheless send a few volts your way...

You see, after 26 years, I've had alot of contact with patients.  And also alot of contact with allergists.  And in general we are compassionate to our patients...with one teensie eensie caveat--

You see, we  allergists are compassionate to patients---on our own terms. 

Conditional compassion.  

Compassion on our terms.   For the diseases we like to treat.

And we've got a bad case.  And this, in my opinion is the real crisis in allergy, not the crisis I spoke about in my earlier blog entry "why we don't need more allergists".   

What is conditional compassion?  It simply means when we see patients who "fit into the box" of our easily treatable diseases--asthma, rhinitis, we like them and have compassion for their plight.  We feel comfortable being around them, teaching them inhaler use, monitoring peak flows, etc.  And it seems more and more allergists are making little asthma clinics and becoming little "asthma doctors", catering mainly to the asthmatic patient, to the exclusion of other patients. Certainly our major allergy societies are codependents in this regard, with their incessant litany of "asthma-this and asthma-that".  So we want asthma patients.  Nothing else, if you please.  But what about the patient who walks in our office with a question on food intolerance? A history of delayed reactions to skin tests or injection immunotherapy?  A history of hyperactivity that seems definitely food related?  Chronic fatigue?   Headaches from foods?  Be honest.  How many of us want to really be compassionate and listen to a patient presenting with multiple complex food and chemical sensitivities?  How truly compassionate are we?  Judging from what I've noticed:

not very.  

Point-in-fact:  , we can't wait to get this type of  patient out of our office.  We find these patients distasteful.  A few perfunctory skin pricks,  a quick pat on the back telling them that they're "not allergic" and whoof!--out the door.  We just don't care. Don't believe me?  Then you're not living in the real world I live in.  I see it all the time as a consulting allergist. Compassion.  Conditional compassion. 

It wasn't always like this.  In the Golden Age of Allergy, allergists were interested in symptoms on all mucosal surfaces and involving multiple body organs--not just the lungs. Allergists really listened to their patients....And when Dr. Francis W. Peabody, on October 25, 1925, ended his lecture to Harvard Medical Students on "The Care of the Patient" he closed with the now classic dictum "the secret of the care of the patient is caring for the patient".  I don't recall he said anything about "caring for the patient with asthma exclusively".  Don't recall that at all.  (But then, again, I wasn't at that lecture in 1925 either...)      

But with conditional compassion the real tragedy is ours.  Not the patients.   Because when we don't care about the patient (except on our terms) , we don't really seek to find out what's really wrong with them if our perfunctory prick tests are negative.  But with compassion comes a sense of urgency--curiosity--in finding out what's really wrong with our patient.  And to seek--and find--what's really wrong with them--allergy or no allergy--, adds to our knowledge.  And with accumulated knowledge and experience comes wisdom. 

So the Spiritual Trinity of the Superior Allergist is compassion--knowledge--wisdom.  But the greatest of these is compassion...and we need more...unconditionally

Later, Dude