Ever get side-tracked, lost your focus, and then shook your head and wondered what WERE you ever doing?  Well, before I got unexpectedly side-tracked by the recent editorial in the Annals of Allergy,  my intent was to use my prior journal entry, The Allergist and The Preschool, as a perfect lead-in to my next topic, "The Total Load" concept.  "The Total Load" concept is, in my opinion, the single most important principle that an allergist can use on a day-to-day basis when dealing with complex allergic cases. Why was the "Preschool" topic so appropriate to the Total Load concept?  I hope it's obvious.  In my parable, the allergist was only "playing" with the blue blocks, neglecting all the others.  Here's a picture of the total allergy load, taken from one of my lectures.  Now, if you can't guess correctly which "block" the typical allergist likes to "play with", I'll degranulate my own mast cells:

You're right--It's the green block. (I thought I'd be sneaky on you and switch colors--from blue to green--but you still figured it out, right?)

Allergists LOVE that green block.  They study every single atom of it...meetings continually FOCUS on the green block. They  focus, study, analyze, scrutinize, ponder, meditate on, think about, concentrate on, ruminate about, and deliberate on it.  But there's one big problem here: 

It's not the only block in the stack.  

Allergists rarely look at the "other boxes" when they try to understand their difficult patients.  We're so addicted to looking ONLY at the green box, we ought to enter rehab.  Now, before you get all agitated, I really don't believe I need to  drop another "black box" warning on you--please rest assured you already "believe in" this concept.  You maybe just don't realize it.  Take a well-respected article on Exercise-induced anaphylaxis to celery.   The authors found that a patient could exercise ALONE without problems, eat celery ALONE without problems, but the COMBINATION of exercise AND celery ingestion caused anaphylaxis.  You remember this concept, right?  It's been reported in other journal articles too...and this is one simple example of The Total Load in action. But there are (trust me) alot more interesting (in my opinion) and varied manifestations of the Total Load phenomenon that you'll see in your everyday practice, if you just look for them.  Just "be curious" (my mantra) and "seek and you shall find".  But before I  go into  specific examples in my next  journal entries, there are two important over-arching principles that help you to "suspect" when you're dealing with a "Total Load" phenomenon in any given patient.

Principle One:  A patient with a fluctuating Total Allergy Load of several items often reports that he/she can SOMETIMES react to an item but not ALL the time. Their reactivity varies depending on their load; It depends on whether their total "block stack" exceeds their allergic threshold.  Depends on the number/size of the blocks they are "playing with".   These patients could drive you nuts if you don't understand what's behind their complaints.  You know the type.  They say that "sometimes I eat this/that food and it bothers me, and sometimes it doesn't", "sometimes I mow the lawn and it bothers me, and sometimes it doesn't"...Sometimes, sometimes, sometimes, sometimes,etc. etc. etc. Often they will go along in this "sometimes I react and sometimes I don't" state for a long time, getting progressively more reactive, until a sudden massive, emergency-room type reaction brings them into my office, and very often you can piece-together the total allergy overload they've had at that point.  An Illustration of the "sometimes I react and sometimes I don't" phenomenon is shown graphically below, where the hypothetical patient reacts to the tourquise item sometimes, and sometimes it is below their "threshold":

Principle Two:  A patient with a  fluctuating Total Allergy Load of several items will RARELY improve if just ONE item is treated.  I see this all the time (and I bet you do too!).  You know this type too.  They have chronic sinus/nasal congestion...you find they are dust mite sensitive and they take a nasal spray and don't get any help.  They quit.  They see the chiropracter.  Stop eating dairy.  Not alot of help either.  They then get on SLIT for inhalants, foods, and moderate their dairy intake and they do great!  The "parable" I use to help explain this to patients is "the person with 3 slivers in their foot."  They find one sliver, remove it.  No help.  So they put the sliver back in their food (it obviously didn't help to have it taken out, right?) and they search for another sliver.  They find it, remove it, --and no help.  So they put it back in too...and on and on it goes...until all the slivers are removed. 

In short, when you see a patient with fluctuating reactions to a variety of exposures/foods and who has tried a number of INDIVIDUAL therapies to help (but to no avail), think about the Total Allergy Load.  

Later, Dude.