As I opened the exam room door, Abbey and Annie were sitting together.  I always enjoyed seeing them.  They seemed inseparable...two sisters who loved to be together and enjoy each other's company.  They had come in a few years ago with similar problems...allergic conjunctivitis and mild perennial congestion with seasonal exacerbations in the spring.  They always preferred to be in the exam room together, and I thoroughly enjoyed seeing them. Not surprisingly, they had similar sensitivities:  inhalant reactions to dust and pollens, and both had a mild milk allergy.

I had placed them both on SLIT, and they had both responded nicely.  But this time as I walked into the room and shook their hands, I sensed immediately that something was terribly wrong.   Abbey was her usual bright and sparkling self, but she shifted her eyes towards her sister, who had a dull, morose expression. I began speaking to Abbey, who seemed more open to talk, and I hoped that would "break the ice" with her sister, who seemed quite withdrawn.

"Abbey", I said, "it's been a while since I've seen you both.  How are you doing?"

"Really pretty good, considering the stress I've been under.  I've lost my job, but am looking for another."

"I'm terribly sorry to hear that.  Stress can really aggravate an allergy condition.  How have you been doing?" I asked.    

"Really pretty well despite everything going on", Abbey said.  "I had some minimal eye itching this spring, and my congestion is under good control.  I haven't needed my antihistamines." 

"That's great", I said.  "Have you been taking your drops?  

"Yes I have.  That's the one thing I've done despite losing my job.  I haven't been too good with dairy restriction though, but it doesn't seem to really bother me."

After further assessing Abbey, I turned my attention to her sister Annie...

"Annie, how have you been doing?"  I asked.

"Not well at all.  I'm not working."  She fidgeted in her chair.  

"Have you lost your job like your sister?"  I asked.

"No, I have been placed on temporary disability.  Too much fatigue and depression.  I don't feel well.  

"What happened?" I said.  "Tell me the story."    

"I've had a rough year since I've seen you.  My eyes have been terrible, and I began to have more and more nasal congestion.  I developed a sinus infection last fall that the doctors couldn't get under control, and then I began wheezing more and more.  Before I saw you, it had been such a rare occurrence that I had forgotten about ever having the problem.  Now I am on inhalers.  Not only that, but my stomach has been acting up, I've had bowel problems and they tell me I now have an "irritable bowel".  As all of this was occurring, I began to get more and more tired, and finally saw a psychiatrist.  I'm on medication, but he agreed that my mental focus and fatigue have been so bad that I can no longer do my job, so he put me on a leave of absence for six months."  With that, she handed me a list of her medications.  

After running through the list of medications she handed me,--and it was now a long list--I mentioned to her that I didn't see her allergy drops listed.

"That's the whole point of wanting to see you again" she said.  "I went off of the allergy drops because my insurance wasn't paying for them, and I want to get back on them."

"This all began when I went off of my drops...."

...I can't begin to tell you the mix of emotions that overwhelmed me at that moment.  It was a combination of anger at the insurance company for their short-sighted efforts at "cost management", my pity for Annie's problems, and my own apparent failure as Annie's physician in emphasizing how important allergy immunotherapy was in maintaining her overall health.  Without SLIT, she had the violent onset of the so-called "allergic march" throughout her system.  Not only were her respiratory tract symptoms spreading, but her bowel problems and even her central nervous system symptoms were in large part from allergy.  In a private practice, we don't have the luxury of doing "clinical trials" with control groups, but there sat her sister, barely 2 feet away, who was stressed from losing her job, and despite her stress was doing excellently while maintaining her immunotherapy.  In my mind, this was as good a "control group" as any.  

As allergists, our use of immunotherapy separates us from our colleagues.  It is our only tool for truly modifying disease. All the drugs in the world can't take the place of one single course of immunotherapy.  

Two sisters.  Two different stories.  One important moral.  

Something to think about.

Later, Dude.