It was a cold day on January 31st when I opened the exam room door, and looked into her eyes.  They revealed a look I've seen before on new patients---a mixture of apprehension, anxiety, and fear. It's a look common to all new patients, even physician's assistants (which she was).  

"Please help me stop my episodes of hives", she said.  "I live in fear of another bad attack." 

"Two months ago, on October 10th.  She replied.  But I've had similar episodes before---they began in June last year, and I've had repeated attacks of generalized hives in August, and again in Septemeber.  But the last one in October was particularly frightening, because I also had wheezing for the first time along with the hives." 

"Well, they've given me the usual Emergency room medications--epinepherine, Solu-Medrol, and antihistamines.  And now I'm on Doxepin 10 mg, Allegra 180 mg bid, and and Zantac 150 mg bid, but I still don't know what causes them or if they will return." 

"Yes, she replied, I've known I've been allergic to shrimp for years, and in fact my prior testing showed some reaction to it.  If I eat shrimp, I get generalized hives. So I don't eat any shellfish.  period.  I haven't had another attack of hives for years--until I began having them starting last June.  It's been a nightmare since then..."

"Do you have the results of your prior tests with you?"  I asked. 

"Yes, here they are", she said

She produced a stack of medical tests, done by a famous midwest clinic noted for its diagnostic expertise. I looked over the medical reports.  They revealed (among the many test results) the following:  normal ESR, tryptase level, peripheral eosinophils, and a host of other normal results.  Interestingly, she had IgE RAST positivity to the following:

IgE shrimp:  8.37

IgE lobster   2.18

IgE Crab      1.71

Normal levels are < 0.35 kU/L.  Obviously, with her prior history, these results didn't surprise me.  But my eyebrows rose when I came across the following test results 

IgE Mite:      6.12

IgE wheat   2.75

IgE  rye        0.72

IgE barley   1.04

She was negative to multiple other foods tests.  And believe me, they tested alot of them...Suspecting she had a low grade "smouldering" food sensitivity going on, I asked about chronic GI problems.  It's an axiom that atopic patients with GERD have a hidden food sensitivity until proven otherwise...

"Oh, yes, I have GERD and some IBS issues...and I'm on Prilosec for them" she replied. 

"How old is your mattress and pillow?" I asked, trying to get a rough handle on her dust exposure.

"Older than dirt" she replied.

I also noted that no basic inhalant tests for pollens or mold had been done, and that her episodes of generalized urticaria (recently accompanied by wheezing) occured from June thru October.  So I asked a very general question:

"Are you involved in alot of outdoor activities during the summer months?"  I asked.

"Well, I garden alot during the summer.  Although I practice medicine in a small town clinic, we actually live on a small acreage and when I bale hay this causes some runny nose and itching, but nothing bad" she said.  I'm exposed outdoors to horses, chickens, and dogs in the barn." 

Initial (pretesting) comments:  Up to this point, I had just interviewed the patient, and had done no testing myself.  But I had a pretty good idea of what was going on.  In my experience, when someone comes in with intermittent severe systemic allergic symptoms, there are usually just two possibilities:  (1)  They are getting intermittent, hidden exposure to an allergen that they are severely allergic to, or (2), they have multiple moderate allergens that cause a "critical mass" effect at certain times, and cause a severe allergic reaction.  In my experience, possibility #2 is much, much more common than possibility number 1.  My working hpothesis was that she had day to day low grade--but clinically significant-- constant exposures to dust mite and wheat, which fluctuated in nature.  She probably had seasonal allergic exposures to mold or pollen which "put her over the top" in terms of having a critical mass or "total load" effect.  Animal dander sensitivity could play a mild role too.  The Total Load Theory is operant in possibility #2 above.  The total load theory is like the theory of evolution--it can't be strictly proven, but it sure makes sense and explains alot of puzzling situations.  I was thinking along the lines of the slide shown below, which is from my powerpoint lecture on the management of the complex allergy patient (available for download).  Every day, her wheat load (the green box), mold load (the yellow box) and the dust mite load (the red box) vary in nature, and sometimes reach a critical mass.  The "allergic threshold" can be lowered by stress.  I wasn't sure about all the boxes in the stack (how many boxes there were and how big each one was) but I was pretty sure these 3 boxes existed, and we were on the right track.  So we did some testing in our own clinic.  Here's what we bound: 

Tests:

intradermal tests:

dust mite:          dilution 5                 10 mm

ragweed            dilution 3                  9 mm

alternaria           dilution 3                10 mm

aspergillus       dilution 2                 11  mm

penicillium        dilution 2                 11 mm

histamine         dilution 2                  11 mm

grass                dilution 2                     neg

tree polllen      dilution 2                     neg

dog                    dilution 2                   10 mm

horse                dilution 3                   10 mm

RAST tests:

antigen                   IgE                         IgG

dust mite              III

egg                        I                             III

pork                       0                            neg

milk                       II                            II                      

wheat                   II                            II

Gluten                   I                            neg

Assessment:

1.  Episodes of generalized urticaria & wheezing secondary to "total load" effect. 

2.  Systemic shellfish sensitivity

3.  Low grade food sensitivities contributing to GERD & IBS and urticarial prediliction

4.  Dust mite sensitivity contributing to urticarial prediliction

5.  Seasonal mold & ragweed sensitivity contributing to urticarial prediliction June--October

One piece of the puzzle remained?  Why did she start to have the problem NOW, at this point in her midlife?  "Well, the clinic has been going thru a huge upheaval recently, and I'm working more hours and am stressed to the max", she said.  The stress load probably increased her susceptibility (or, putting it another way, lowered her threshold) towards having clinically significant allergy problems. 

So, in a patient predisposed in her family to get allergies (like her father & sister before her), she's working long hard hours, getting plenty of dust and mold exposures on her small farm acreage, eating too much wheat, and the critical mass effect...happens.  

So, like a wise old allergist once taught me:  "The 3 basic principles of treatment for the patient consist of---diagnosis, diagnosis, and diagnosis.  In short, her treatment approach was to remember the basic equation for all allergic reactions:

allergic reaction = sensitivity x allergic load

So I simultaneously began her on a SLIT program to reduce sensitivity, while also reducing her allergic load:

1.  Begin SLIT to dust mite, mold, ragweed, wheat, egg, milk

2.  Reduce wheat ingestion by 50%--i.e., avoid snacking on "extra wheat" and use it for essential purposes only.

3.  Cover old mattress and pillows with dust mite barrier encasings

4.  Continue antihistamine coverage. 

Clinical progress:  One episode of generalized urticaria immediately after starting treatment, occuring at 10:55 AM on the morning of March 5th 31 days into Rx.    When I spoke with her, the reason was obvious---she had been vacuuming up a dead plant that had fallen over in her home, and then changed the vacuum bag and got a large dose of combined dust and mold together.  She immediately started with hives on her neck and wheezing.  Prednisone, epipen, and benadryl were used with resolution of symptoms.  I spent time discussing the Total Load Effect with her, and since then she has been asymptomatic this summer and fall, and has stopped zantac, eliminated one of her two daily allegra, and will probably go off of the last one soon.  Her GI tract--surprise!--has been excellent, and she can do more farming work without low grade rhinitis and pruritis. 

Important points

 Nearly everything needed to explain the patient's problems had been found through prior  tests at the other clinic.  The problem with this patient's management was twofold:

1.  No one had "put the pieces" together and looked at her from a "Total Load" standpoint.  Allergists like to deal with one allergen at a time.  Failure to address multiple allergens and their interactions is a common mistake. 

2.  No one had offered her immunotherapy, and that's where SLIT shines.  It can be begun rapidly and broadly to              every component of her total load. 

Will these common mistakes by allergists continue to be made in the future?  That, my friends, is an itch that can't be scratched.....

Later, Dude