In my last entry, I promised to write about one clinical pattern (mold and Candida cross-sensitization) but that all changed when I recently received the following e-mail from a savvy Physician's Assistant who is a friend of mine.  Here's the key excerpt:  

"...13 year old with 5+ years of vomiting 10 to 12 times daily on and off.  Had seen gastro multiple times with no answers.   Saw me and I suggested wheat free, dairy free diet and ran a RAST IgE food panel on him.  He came back positive to eggs at 3+, dairy 2+, wheat at 2+ and soy at 1+.    Took him off of all of these and his symptoms resolved almost completely...He did see GI after this again and was told he may have eosinophilic esophagitis based on endoscopy and some "general inflammation".    Also sent him to allergy and they said he didn't really have true food allergies despite positive RAST and a clear improvement off of the offending atents.  They in fact suggested he go BACK on his foods and that his underlying issue may in fact be eosinophilic esophagitis.  

Are the allergists here in question total morons...?  My understanding is that studies have been done show that an elemental or elimination diet can resolve some cases of Eosinophilic esophagitis and patient symptoms.  Isn't this a clear allergic issue?   I also suggested to my patient's mother to ask about SLIT to the allergist just to see what would occur and the note returned to me clearly states "patient's mother asked about SLIT which we discouraged considering because it hasn't been shown to work". 

   This letter pretty much sums up the frustration many primary care doctors have in dealing with allergists...in this case, there is a failure by the allergist in question in two separate areas:

1. A failure in focusing on  a disease and disregarding potentially  causative triggers of the disease.  

2. A failure in recognizing that a fluctuating load of "low grade" allergens can cause a "critical mass" effect of an acute allergic reaction...i.e., a failure in "pattern recognition".  

Let's discuss the first of these two failures:  

I have previously written on Jerome Groopman's excellent book, "How Doctor's Think" In the book there is an interesting story told by an ER doctor...a elderly man presented with a broken ankle.  The ER physician focused on fixing the ankle...and the man presented later to the ER...having fallen again.  It turned out the reason he had fallen--and broken his ankle--was because he was weak and anemic.  And it turns out he was anemic because...he had colon cancer.  So the ER doctor focused on the illness, to the exclusion of inciting triggers for the illness.  With disastrous results.  In a similar manner, the physician's assistant is really asking in his email:  "do we really do a "complete" service to our patient by focusing on whether or not he has an illness (i.e., eosinophilic gastroenteritis--or eosinophilic esophagitis) if we ignore possible causative triggers--in this case the dietary management that put the child in remission?  

The second failure in the above case is the failure of pattern recognition:  we can often have patients present with intermittent severe allergic-type reactions.  More often than not, there are only two possibilities for these intermittent severe reactions:  i.e., a HIGHLY allergenic item (usually hidden to the patient) that he/she intermittent has exposure to, or (and this is far more common), an accumulation of MILDLY alllergenic products reaching a "critical mass" in unfortunate circumstances.  I have seen this scenario played out multiple times in diseases such as "idiopathic anaphylaxis".  

It's important to understand that low grade food sensitivities can be responsible for intermittent severe attacks of GI upset.  The child's symptoms were "off and on", and resemble the clinical entity Cyclic Vomiting Syndrome.  There is medical literature to support the idea that Cyclic Vomiting Syndrome can be a manifestation of allergic gastroenteritis, which in turn can be triggered by food allergy.  Tokodi et al presented the case of Cyclic vomiting syndrome in a child which resolved on elimination of milk from the diet.   Further, Lucarelli et al, writing in the Eur J Pediatrics  had this to say:  

Cyclic vomiting syndrome (CVS) is characterized by repeated unpredictable, explosive and unexplained bouts of vomiting. The episodes have a rapid onset, persist over a number of hours or days, and are separated by symptom-free intervals. Despite the recent interest in this disorder, its aetiology, pathogenesis and even its target organ remain unknown. The purpose of this study is to investigate the role played by food allergy in CVS. The report concerns eight children (five male, three female), mean age 8 years (3-13 years), suffering from CVS for 2 years at least. The diagnosis of CVS was based on characteristic history, normal physical examination and negative laboratory, radiographic, neurological and endoscopic studies. Despite the absence of clinical signs typical of food allergy, skin prick tests were positive in six of the eight patients (75%). Specific IgE were present in 4/8 (50%) of the patients. Skin tests and specific IgE were positive for cow's milk proteins, egg white and soya. IgE levels were higher than the mean + 2SD in 5/8 (63%) of the patients. A double blind placebo controlled food challenge (DBPCFC) was carried out on seven of the eight patients who displayed clinical improvement after an elimination diet for cow's milk (and other foodstuffs indicated by positive skin tests). The DBPCFC was positive in all seven children. Clinical follow-up revealed a state of well-being over the 6 months of observation. CONCLUSION: It appears reasonable to suggest that food allergy plays a role in cyclic vomiting syndrome.

I have seen the pattern of intermittent GI upset (particularly in children) from mild food sensitivities in many children.  More often than not, the mother or father will bring their child in to me because they are having a few episodes a month of severe gastrointestinal distress.  Very often, there is a low grade reaction to one or more foods responsible for the episode.  Remember:  it takes 3 1/2 days for food to completely transit the GI tract, so a "load effect" can take place.  Case in point:

A minister sees me in the office.  He has ice cream as his "special treat" every Friday night.  Last month it was his birthday--on a Saturday--so he had his ice cream Friday AND Saturday--and he suffered a horrible attack of GI distress and upper respiratory congestion on Sunday morning!

This is graphically illustrated in the following slide:

In this slide, the fluctuating size bars represent the fluctuating levels of food allergens present in the patient's system, which in turn are shown by the different colored boxes.  The threshold for reaction, shown as a dotted line, can be lowered by stress (viral infection, emotional trauma, etc). 

In another part of his email, the physician's assistant related that "the allergist said that those RAST levels were not positive enough to be a problem".  Nothing could be farther from the truth.  Like the statement by the allergist that "SLIT doesn't work".  Enough now.  I'm going to take my high BP pill and sign off. 

Later, Dude