Throughout our lives, allergists listen to tales...and in the end, we become a storytellers, full of fascinating clinical viginettes from our experiences in caring for allergy patients.  A recently article, entitled "The tale of the Allergists life:  A series of interesting case reports" by Ray Slavin, M.D.  in Allergy Asthma Proc. 2008 Jul-Aug;29(4):417-20, emphasizes this fact.  A few quotes from the article are worth noting:

"I want help with my neuropathy", he said.  "I've been to the University of XX and after a detailed workup, they diagnosed idiopatic neuropathy.  I began gabapentin in 2005.  I continued with my symptoms and saw another neurologist for a second opinion, and after a further series of tests, I was given Lyrica to counteract the pain in my feet and legs in 2006.  However, Dr. X is questioning the diagnosis of peripheral neuropathy, because I have tingling in my face, neck and back as well as my feet and legs, and he prefers to call it an immune or inflammatory neuropathy."  

"I began weekly infusions of one gram of methylprednisolone in April of last year (2007), and these were changed to every other week in June of this year (2008).  I immediately noticed benefits--dramatic lessening of need to take Gabapentin for pain, I had better balance, and a return of skin sensitivity where I was previously numb." 

"Tell me about your current symptoms", I said.

He looked at me sadly, then began:

"I have a real struggle with my balance for the last couple of years, but the big thing is that I have terrible numbness and  tingling in the legs and feet, below the knees.  There is tingling, and some pain however, in all areas above the knees, including the face, neck, back, hands, and arms. The feet and lower leg pain and numbness is present most of the time, but can be reduced by the steroid infusions, which reduce the need for pain meds consideratly.  I take the infusions on Monday and initially get good relief, but by Thursday, the pain and tingling in the lower legs recurs with a terrible vegance."

"Tell me about your alcohol ingestion", I said.  

He looked at me.  

"I'll be honest with you.  I had considerable alcohol consumption from about 1966 to 1975, then a period of no consumption lasting until about 1983.  Then I again had heavy consumption lasting until about 1995, then again a period of no consumption for 4 years.Then I began to drink heavily again, and haven't had a drink since Feb of 2004.  I attend AA meetings now."  

"Any respiratory problems?" I asked.

"I've got some nasal drainage and cough in the fall, but that's a minor issue" he said.

"How about your diet and your intestinal function?" I asked.

"Well, I am bothered by alot of intestinal bloating and gas" he admitted.  "I've also found that some foods aggravate my pain--yogurt, peanut butter, nuts, citrus all intensive the symptoms in my feet and legs so I avoid them. "

I looked at the personal questionnaire he had typed out before the visit.  He had a litany of problems in addition to his presenting one:  glaucoma, rosacea, gout, sleep apnea, venous stasis dermatitis, tinnitus, hypertension, and a prior history of nasal polyposis.  

When I examined him, he needed a cane for walking, and although his Romberg was intact, he had a very unsteady heel-to-toe walk, for which he needed assistance.  He had decreased knee reflexes bilaterally, but at the time of exam, sensory exam was intact to light touch on both legs.  Pedal edema was noted bilaterally.  Mild pharyngeal posterior nasal drainage was seen.  

                                  Tests:

IgG RAST:

Egg--Class II

Dairy--Class II

Wheat--Class I

Corn, peanut, soy, yeast, gluten--Negative

Celiac Antibodys:

Gliadin IgA    9.45 (nl <5)

Gliadin IgG   6.98  (nl <7)

Tissue Transglutaminase IgA    2.31 (nl <20)

Challenge Tests:

milk:  increased pain, tingling in feet, swelling sensation in feet, imbalance & unsteady; flu-like sensation throughout body; increased pain in forehead & cheeks; increased impairment on heel-to-toe walking (on exam)

corn:  increased impairment on heel-to-toe walking (on exam), slight numbness in feet

gluten: incresed impairment on heel-to-toe walking (on exam), weakness on walking

yeast:  heavy sensation in legs "felt like wooden blocks"., slightly unsteady heel-to-toe walk

Candida:  pain increasing from feet up to legs, heavy sensation in legs, 

IDT Tests:

Antigen                          Immediate rxn               Delayed rxn

dust                                  8mm dil 2                         +

alternaria                           9 mm dil 1                        ++

Cladosporium                    9 mm dil 1                        ++

Candida                            8 mm dil 2                        +++

Histamine control              10 mm dil 2

Pollens (tree/grass/weed)    6 mm dil 2    

Assessment:

1.  Neuropathic pain, multifactorial, related to former alcohol abuse,--variant nature of pain related to celiac disease, food sensitivities, and Candida related illness.

2.  Abnormal celiac antibodies, with evidence of gluten sensitivity clinically on challenge

3.  Abnormal IgG antibodies to dairy & egg, with evidence of dairy sensitivity clinically on challenge

4.  Abnormally strong ID delayed reaction to Candida, with evidence of Candida and food yeast sensitivity on challenge

5.  Impaired gut integrity, with increased intestinal permeability likely, as a result of chronic alcohol use, and celiac disease, and enhanced carriage of Candida in gut secondary to chronic antibiotic use for rosacea

6.  Chronic Tinnitus probably aggravated by allergy

7.  Mild mold sensitivity causing seasonal fall congestion.

8.  Sleep apnea

9.  Hypertension

10. Rosacea

11. Glaucoma

12. Chronic tinnitus

13. Venous stasis dermatitis

14. Penicillin allergy

15. s/p nasal polyposis

16. gout

Discussion

Here is my "discussion" that I shared with my patient in writing: 

"I mentioned to Mr. X that I felt it would be possible that low grade food sensitivities have been worsened following a probable increase in intestinal permeability that could have occured as a result of chronic alcohol ingestion historically.  His use of antibiotics chronically since 1999 for Rosacea could have caused Candida overgrowth and further impairment in intestinal integrity and heightened intestinal permeability or "leaky gut". The combination of alcohol ingestion and increasing Candida growth could have, in summary, caused a leaky gut with more food reactions developing.  Clinically, he is already aware that certain foods bother him and seem to increase neuropathic pain.  This would include yogurt, raspberries, peanut butter, nuts, and citrus.  The fact that he has a very atypical neuropathic pain problem, with no concurrent muscle wasting, and the fact that his symptoms include intestinal issues, and areas of involvement outside of his lower legs per se would suggest that food sensitivities and yeast issues are aggravating his condition..."  

1.  SLIT for offending foods

2.  Rotary-diversified elimination diet, both gluten and dairy free, and also eliminating eggs, yeast, citrus, corn, tomatos, nuts.  

3.  Nystatin antifungal medication, probiotics

4.  Continuation of medications, except for doxycycline

5.  Continuation of vitamin supplements already on

Treatment course:

When I saw the patient back in the clinic, he was no longer using a cane.  His heel-to-toe walk was unimpaired, and could be done without assistance.  He handed me a written summary of his progress: 

"My strength and stamina have increased dramatically since going on the diet 3 months ago... I have rapidly lost 40 pounds to date, and have eliminated the taking of protonix and gabapentin.  I have reduced the steroid infusions to once every three weeks.  Neuropathic pain still remains if I don't take Lycra, but greatly reduced.  It appears that an element of neuropathy is reversing as I seem to have more control over the awareness of the need for urination and defecation and sexual responsiveness is improved.  

As Grossman points out in his article, , 

"This literature has become quite controversial, with disputes over the definition of coeliac disease and gluten sensitivity, whether neurological complications are caused by coeliac disease or are epiphenomena, and whether the proposed complications respond to a gluten-free diet."

Later, Dude

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