Go ahead.  Try it out.  Make my day.  Try to find case histories on SLIT in medical journals.  Sorry, pal, but you won't find any.  None at all.  Zip.  Well, somebody has to start producing case reports on Sublingual Immunotherapy (SLIT) use, right?  Alright, it's a dirty job, but somebody has to do it, and so, since I've had 27 years of experience with SLIT, here goes....

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 usage 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